Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by the physician for two residents with significant respiratory and cardiac conditions. For one resident with diagnoses including pneumonia, acute respiratory failure, COPD, and CHF, the physician's order specified oxygen at 1 liter per minute (LPM) via nasal cannula, with nurses required to check the delivery rate every shift. However, observations on two occasions revealed the resident was receiving 3.5 LPM, and both the registered nurse and assistant director of nursing confirmed the oxygen was not set according to the physician's order. The nurse admitted she had not checked the oxygen settings that day, despite being responsible for verifying the rate each time she entered the room. Another resident, with a history of cerebral infarction, hemiplegia, CHF, adult failure to thrive, and quadriplegia, had a physician's order for continuous oxygen at 2 LPM via nasal cannula. Observations showed the resident was receiving only 1.5 LPM on two separate occasions. The assigned LPN confirmed she had not checked the concentrator settings that day and verified the flow rate was below the ordered amount. The director of nursing stated that nurses were expected to check the oxygen flow rate at eye level at least every shift and ensure administration matched the physician's order. The facility's policy required oxygen to be administered as ordered by a physician, consistent with professional standards and the resident's care plan.