Failure to Administer Oxygen Therapy at Physician-Ordered Flow Rate
Penalty
Summary
A deficiency was identified when a resident receiving oxygen therapy was administered oxygen at a flow rate of 1.5 liters per minute (lpm) via nasal cannula, instead of the physician-ordered rate of 1 lpm. This discrepancy was observed during multiple visits to the resident's room, and was confirmed by a licensed vocational nurse (LVN) who acknowledged that the oxygen flow rate being delivered did not match the physician's order. The LVN stated that the correct procedure would have been to follow the doctor's order for oxygen therapy. The resident involved had a medical history including chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure (CHF). The facility's policy on oxygen administration requires verification and adherence to physician orders, as well as proper adjustment of the oxygen delivery device. The director of nursing (DON) confirmed that nurses are expected to review and follow physician orders for oxygen therapy and to ensure accurate flow rate administration.