Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
Staff failed to deliver oxygen therapy according to the physician's order for a resident with chronic obstructive pulmonary disease (COPD), cough, and pleural effusion. The physician's order specified continuous humidified oxygen at 2-4 liters per minute (LPM) via nasal cannula. However, multiple observations over three consecutive days showed the resident receiving oxygen at 5 LPM, which exceeded the ordered range. During an interview, an LPN confirmed that the oxygen concentrator was set to 5 LPM and acknowledged the discrepancy after reviewing the physician's order. The Director of Nursing stated that nurses are expected to follow physician orders for oxygen administration and that any changes require a new order and family notification. The failure to adhere to the prescribed oxygen flow rate constituted the deficiency.