Failure to Administer Supplemental Oxygen as Ordered
Penalty
Summary
The facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two residents. For one resident with chronic obstructive pulmonary disease and polyneuropathy, the physician ordered oxygen at 2 liters per minute via nasal cannula. However, during observation, the oxygen was set at 3 liters per minute. The unit manager confirmed the discrepancy and noted that the setting should have been 2 liters, while the resident denied changing the oxygen setting. For another resident with acute on chronic diastolic heart failure and chronic atrial fibrillation, the physician ordered oxygen at 3 liters per minute via nasal cannula. Observation revealed that the oxygen was set at 2 liters per minute. The unit manager confirmed this observation. These findings indicate that the facility did not follow its own policy and physician orders regarding oxygen administration for these residents.