Failure to Administer Oxygen at Physician-Ordered Flow Rates
Penalty
Summary
The facility failed to administer oxygen at the physician-ordered flow rates for two residents who required respiratory care. For one resident with diagnoses including acute and chronic respiratory failure with hypoxia, COPD with acute exacerbation, pneumonia, and congestive heart failure, oxygen was observed being administered at 4 liters per minute via nasal cannula, despite a physician order specifying 2 liters per minute. The resident's care plan also indicated that oxygen should be provided as per the medical doctor's order. During staff interviews, an LPN acknowledged that the oxygen was set higher than ordered and stated that oxygen levels are typically checked after medication passes, but had not yet been checked for this resident. A second resident, with diagnoses including acute and chronic respiratory failure with hypercapnia, COPD with acute exacerbation, respiratory failure with hypoxia, atherosclerotic heart disease, paroxysmal atrial fibrillation, and obstructive sleep apnea, was observed receiving oxygen at 4 liters per minute, while the physician order specified 3 liters per minute. The oxygen concentrator was positioned outside the resident's reach and facing the wall. The resident reported that only nurses adjust the oxygen, and the LPN interviewed was unsure how the discrepancy occurred, stating that oxygen and oxygen saturations should be checked daily. The facility's policy requires oxygen to be administered according to physician orders and professional standards of practice.