Failure to Monitor and Administer Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident who was prescribed continuous oxygen therapy at 1 liter per minute (LPM) via nasal cannula was found to be receiving oxygen at a higher flow rate of 2 LPM. The oxygen concentrator was positioned behind the resident's wheelchair and was not within her reach. The resident, who is cognitively intact but dependent on staff for all activities of daily living, reported that staff typically check her oxygen in the morning and that she does not adjust the setting herself. However, there was inconsistency among nursing staff regarding the necessity of oxygen therapy for this resident, and the resident expressed confusion about why she was on oxygen. Upon review, a registered nurse confirmed that the physician's order specified 1 LPM and that there was no order to titrate the oxygen. The nurse adjusted the flow rate to the correct setting. The resident's clinical records indicated diagnoses including pneumonitis, congestive heart failure, and acute pulmonary edema, and her care needs required staff assistance for mobility and personal hygiene. The facility's policy requires verification and monitoring of oxygen administration according to physician orders, but this was not followed, resulting in the resident receiving an incorrect oxygen flow rate.