Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for one resident who required continuous oxygen therapy. The resident, who had a history of heart and kidney disease, neurogenic bladder, urinary tract infection, and chronic respiratory failure with COPD, had a provider's order for oxygen at 3 liters per minute (LPM) via nasal cannula every shift. The resident's care plan also specified continuous oxygen therapy at the ordered rate, with licensed nurses responsible for administering oxygen as ordered. Despite these orders, observations on multiple occasions showed the resident receiving oxygen at a flow rate of 4.5 LPM, which exceeded the provider's order. During interviews, an LPN acknowledged that the oxygen flow rate had been increased without a provider's order and stated they would return it to the prescribed 3 LPM. The DON confirmed that the expectation was for staff to follow the provider's order and not change the oxygen setting without authorization. This failure to adhere to the ordered oxygen flow rate constituted a deficiency in providing safe and appropriate respiratory care.