Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
Staff failed to follow a physician's order for oxygen administration for one resident diagnosed with chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. The physician's order specified that oxygen should be administered at three liters per minute (LPM) via nasal cannula, continuously. However, during multiple observations over two days, the resident was found to be receiving oxygen at only two LPM. An LPN responsible for the resident's care confirmed that she did not check the oxygen setting during her medication passes on the observed days and verified that the oxygen was set at two LPM, not the prescribed three LPM. The Director of Nursing stated that staff are expected to ensure oxygen is administered as ordered and that nurses should check oxygen settings during medication passes and rounding.