Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
Staff failed to administer oxygen therapy to three residents in accordance with physician orders. For one resident with COPD and acute respiratory failure, observations showed oxygen was delivered at 3.5 LPM via nasal cannula, despite a physician order for 2 LPM continuously. Another resident with COPD was observed receiving oxygen at 4.5 LPM, while the physician order specified 2 LPM. The respiratory therapist acknowledged increasing the flow rate due to a low oxygen saturation reading but confirmed this was not per the physician's order. The Director of Nursing confirmed that both residents were receiving oxygen at incorrect flow rates and stated that staff should not alter oxygen flow without a physician's order. A third resident, with COPD and chronic respiratory failure, was observed receiving oxygen at 3.5 LPM, though the physician order was for 2 LPM. The resident reported that the oxygen had been set at 3.5 LPM since admission, and a nurse confirmed the discrepancy between the order and the administered flow rate. The nurse also stated that it was the responsibility of nursing staff to ensure the correct oxygen flow rate. These findings were based on observations, staff interviews, and review of medical records and facility policy.