Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician orders for four residents who were receiving oxygen therapy. Observations revealed that each resident was receiving oxygen at a higher flow rate than prescribed. For example, one resident was observed receiving oxygen at 4 liters per minute (LPM) when the physician order specified 2 LPM as needed for shortness of breath, and another was receiving 5 LPM when the order was for 3 LPM. In each case, the oxygen concentrator was placed outside the resident's reach, and residents reported that only staff handled the oxygen equipment. Interviews with nursing staff confirmed that the oxygen flow rates being administered did not match the physician orders, and staff acknowledged the discrepancies during the survey. Staff also indicated that they were responsible for checking and adjusting the oxygen flow rates, but these checks were not consistently performed as required. The Director of Nursing confirmed that staff should ensure oxygen is administered at the ordered rate, but this was not done for the residents in question.