Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician for a resident with significant medical conditions, including acute ischemic heart disease, carotid artery occlusion, cerebral infarction, and hypertension. The resident was severely cognitively impaired and had a physician's order for oxygen at 3 liters per minute (L/min) as needed for shortness of breath, to maintain oxygen saturation above 91%. However, review of the Medication Administration Record showed no documentation of PRN oxygen administration, and multiple observations revealed the oxygen concentrator was set at 1.5-2 L/min, not the ordered 3 L/min. During interviews, an LPN initially stated the order was for 2 L/min, then acknowledged it had changed to 3 L/min, and subsequently adjusted the oxygen setting to 3 L/min during the surveyor's presence. The Director of Nursing confirmed that staff are expected to follow physician orders for oxygen settings. Facility policies also require staff to review and implement physician orders as written, but these were not followed in this instance.