Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that two residents with chronic obstructive pulmonary disease (COPD) received oxygen therapy as ordered by their physicians. For one resident, the physician's order specified oxygen at 2 liters per minute (LPM) every shift, but during observation, the resident was found receiving only 1.5 LPM. The licensed vocational nurse (LVN) confirmed that the resident should have been on 2 LPM as per the physician's order. Similarly, another resident with a COPD diagnosis had a physician's order for oxygen at 2 LPM every shift for symptoms of shortness of breath and chest pain, but was observed receiving only 1.2 LPM of oxygen. The LVN also confirmed this did not match the physician's order. Review of the facility's policy on oxygen treatment indicated that oxygen therapy should be administered as ordered by the physician, including adjusting the oxygen flow as specified. The observations and interviews demonstrated that the facility did not follow physician orders for oxygen administration for these two residents, resulting in a failure to provide safe and appropriate respiratory care as required.