Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident by not administering oxygen therapy as ordered by the physician. During an observation, the resident was found lying in bed with oxygen tubing labeled and dated, but the nasal cannula was not placed on the resident's nares. The oxygen concentrator was set at 1 liter per minute, which was inconsistent with the physician's order for 2 liters per minute via nasal cannula every shift to maintain oxygen saturation above 92%. The resident's care plan also specified the need for oxygen at 2 liters per minute due to altered respiratory status. Interviews with facility staff confirmed that the oxygen concentrator had been replaced due to malfunction, and the dial to set the oxygen flow was not working. Staff acknowledged that the physician's order for oxygen administration should have been followed, and the DON confirmed awareness of the findings. The resident was noted to have no capacity to make health care decisions but could express simple needs. The failure to follow the physician's order and ensure proper oxygen administration constituted a deficiency in providing safe and appropriate respiratory care.