Failure to Administer Supplemental Oxygen per Physician Orders
Penalty
Summary
A resident with diagnoses of chronic obstructive pulmonary disease (COPD) and chronic respiratory failure was observed receiving supplemental oxygen at flow rates higher than those ordered by the physician. Multiple observations showed the resident receiving oxygen at four and five liters per minute via nasal cannula, while the physician's order specified oxygen at two liters per minute as needed. The resident's care plan instructed staff to check oxygen settings and provide oxygen as ordered, referencing the physician's orders. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the oxygen concentrator was set above the ordered rate and that the resident was unable to adjust the flow independently due to physical limitations. The facility's policy required staff to check the physician's order for liter flow and set the flow meter accordingly, but this was not followed, resulting in the resident receiving oxygen at a higher rate than prescribed.