Failure to Administer Oxygen Therapy per Physician's Order
Penalty
Summary
The facility failed to provide oxygen therapy according to the physician's order for a resident with chronic obstructive pulmonary disease (COPD), diabetes, and high blood pressure. The physician's order specified oxygen at 1 liter per minute (lpm) via nasal cannula as needed for shortness of breath or comfort. However, observations on two separate occasions revealed the resident was receiving oxygen at 3.5 lpm, which was not in accordance with the order. A Licensed Practical Nurse confirmed that the oxygen concentrator was set at 3.5 lpm, and the Nursing Home Administrator acknowledged that the resident had a habit of changing the concentrator settings. Despite being aware of this behavior, the facility did not provide evidence of implementing routine interventions to ensure the oxygen flow rate was maintained as ordered by the physician.