Failure to Administer Oxygen at Physician-Ordered Flow Rates
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for oxygen administration for three residents with diagnoses including COPD, asthma, emphysema, and respiratory failure. For one resident, physician orders specified continuous oxygen at 2 liters per minute (LPM) via nasal cannula, but observations on multiple occasions found the oxygen being administered at 3 LPM. Staff interviews confirmed the discrepancy and indicated the resident was unable to adjust the oxygen flow independently. Another resident with orders for oxygen at 3 LPM via nasal cannula was observed receiving oxygen at 2 LPM during several checks. Staff confirmed the oxygen was not set at the ordered rate, and the resident reported not knowing how to change the flow. A third resident, dependent on oxygen with orders for 2 LPM, was observed receiving 3.5 LPM, with staff noting the resident could not adjust the flow and suggesting it may have been inadvertently changed by staff. Facility policy required verification and adherence to physician orders for oxygen administration, but these were not consistently followed.