Failure to Maintain Physician-Ordered Oxygen Flow Rate
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, atrial fibrillation, altered mental status, and chronic kidney disease was administered oxygen at a flow rate higher than the physician's order. The resident, who had severely impaired cognition, had an active physician's order for oxygen at 2 liters per minute (LPM) via nasal cannula. However, during observation, the oxygen concentrator was set at 3 LPM. The nurse assigned to the resident, who was new to the unit and covering for another staff member, initially believed the correct flow rate was 3 LPM and did not verify the physician's order before administering the oxygen. Upon review, the nurse acknowledged the error after checking the medical record and realizing the order was for 2 LPM. The Staff Development Coordinator and Director of Nursing both confirmed that nurses are expected to verify physician orders, and the facility's policy directs staff to set the oxygen flow rate as ordered by the physician. The care plan for the resident did not indicate any behaviors that would have led to refusal or adjustment of the oxygen flow rate.