Failure to Administer Oxygen per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, hypertension, dyspnea, and asthma was administered supplemental oxygen at a rate of 4.5 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This was observed during a routine check, and the Infection Preventionist confirmed that the oxygen setting was not in accordance with the physician's order. The physician order summary and progress notes did not indicate any clinical justification or documentation for increasing the oxygen flow above the prescribed amount. Interviews with facility staff, including the Infection Preventionist, Minimum Data Set Nurse, and Director of Nursing, confirmed that the oxygen administration did not follow professional standards or facility policy, which require verification and adherence to physician orders for medication administration, including oxygen. The facility's policy and job descriptions also specify that licensed nurses are responsible for reviewing and following physician orders, but this was not done in this instance.