Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
Staff failed to administer oxygen therapy as prescribed by physicians for two residents with respiratory conditions. One resident with diagnoses including sarcoidosis, shortness of breath, and eosinophilic asthma had a physician's order for oxygen at 3 liters per minute (LPM) via nasal cannula as needed. However, observation revealed the oxygen flow rate was set between 1.5 and 2 LPM, and the resident reported not feeling the oxygen flow, prompting her to call for a nurse. The resident's care plan and medical record confirmed the need for oxygen at the ordered rate. Another resident with a diagnosis of acute respiratory failure with hypoxia had a physician's order for continuous oxygen at 3 LPM. Observations showed the nasal cannula was not consistently in place, and the oxygen flow meter was set below the prescribed rate on multiple occasions, including 2.5 LPM and 1 LPM. Interviews with nursing staff and the Director of Health Services confirmed that the expectation was for staff to review and monitor oxygen orders and settings each shift, but this was not consistently done.