Failure to Administer Oxygen per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of anxiety disorder was not provided respiratory care services in accordance with the physician's order. The physician had ordered oxygen to be administered at two liters per minute via nasal cannula as needed for shortness of breath. However, during an observation, the resident was found receiving oxygen at only one liter per minute while still experiencing shortness of breath. This discrepancy was confirmed by a licensed nurse, who acknowledged that the oxygen concentrator was set below the ordered rate. The Director of Nursing stated that the expectation was for nurses to follow the physician's order accurately to ensure proper care. A review of the facility's policy on oxygen administration also indicated the need to verify the physician's order, including the rate of oxygen flow.
Plan Of Correction
All corrective action will be completed by 5/26/25.