Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by the physician for two residents. For one resident with chronic respiratory failure and obstructive sleep apnea, the physician's order specified oxygen therapy at 2 liters per minute (L/min) as needed. However, observations on two separate occasions showed the resident receiving oxygen at 4 L/min. A registered nurse confirmed that the oxygen should have been set to 2 L/min at all times when in use, as per the physician's order. For another resident with pleural effusion and pneumonia, the physician's order required oxygen therapy at 2 L/min, with the option to increase up to 5 L/min. During observation, this resident was receiving oxygen at 1.5 L/min, which was below the minimum rate specified in the order. The registered nurse acknowledged that the therapy should have been administered at a rate of at least 2 L/min. The facility's policy required staff to ensure oxygen therapy was administered as ordered by the physician.