Failure to Administer Oxygen Therapy per Physician's Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician's orders for one resident. The resident, who had a diagnosis of chronic respiratory failure with hypoxia, had a physician's order for oxygen to be delivered via nasal cannula at 2.0 liters per minute. However, during an observation, the oxygen concentrator was found set at 0.0 liters per minute, and the resident reported not feeling any airflow from the nasal cannula. The facility's policy requires licensed nurses to initiate and monitor oxygen therapy per physician's orders, but this was not followed in this instance. A review of the clinical record and interviews confirmed that the resident should have been receiving continuous oxygen at the prescribed rate. The discrepancy was identified during a staff interview, and it was acknowledged that the oxygen was not being administered as ordered. The resident's blood-oxygen saturation was measured at 93% at the time of the incident, and the resident denied experiencing shortness of breath or distress. The Nursing Home Administrator confirmed the facility's responsibility to ensure that care is provided in accordance with physician's orders and the resident's plan of care.