Failure to Administer Oxygen as Ordered for Resident with COPD
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of chronic obstructive pulmonary disease (COPD) did not receive oxygen therapy as ordered by the physician. The physician's order specified continuous oxygen via nasal cannula at 5 liters per minute, with titration to maintain oxygen saturation above 90%. However, observations revealed that the resident's oxygen concentrator was set to deliver only 2 liters per minute. Nursing staff confirmed the concentrator was set at 2 liters and acknowledged the order was for 5 liters, but did not verify the flow rate during their checks, only noting the resident's oxygen saturation was 93%. The facility's policy required staff to follow physician orders for oxygen administration, but this was not done in this instance.