Failure to Provide Oxygen at Prescribed Flow Rate
Penalty
Summary
The facility failed to ensure that a resident with a myoneural disorder requiring continuous oxygen therapy received oxygen at the prescribed flow rate as ordered by the physician. The physician's order specified oxygen at 3 liters per minute (LPM) via nasal cannula continuously to relieve hypoxia. However, multiple observations over several days revealed that the resident's oxygen was set below the prescribed rate, ranging from 1.5 to 2 LPM on both the oxygen concentrator and portable oxygen tank. The resident was observed in various settings, including in bed and in a wheelchair, with the oxygen flow rate consistently set lower than ordered, although the resident was not in visible distress during these observations. Interviews with the resident confirmed that she did not adjust her own oxygen settings and relied on nursing staff for this task. Nursing assistants (NAs) and nurses provided conflicting accounts regarding responsibility for setting and adjusting the oxygen flow rate. Some NAs reported that they set the flow rate on portable tanks when transferring the resident, while others stated that only licensed nurses should perform this task. Nurses acknowledged that the flow rate should match the physician's order but admitted to not always checking the settings during their rounds. Leadership staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, all stated that only licensed nurses should set or adjust oxygen flow rates and that NAs should not be responsible for this task. Despite these expectations, the practice observed and described by staff interviews indicated that NAs were sometimes adjusting oxygen flow rates, leading to the resident not consistently receiving oxygen at the prescribed rate.