Failure to Administer Oxygen as Ordered by Physician
Penalty
Summary
A deficiency occurred when a male resident with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), was administered oxygen at a rate of 5 liters per minute via nasal cannula, despite a physician's order specifying 3 liters per minute. The discrepancy was discovered during an observation, where the oxygen concentrator was found set at 5 liters. The LPN present confirmed that the correct setting should have been 3 liters, as per the active physician order, and acknowledged that oxygen is considered a medication that must be administered as ordered. The LPN also admitted that she had not checked the oxygen concentrator that day and was unaware of the incorrect setting until it was pointed out by the surveyor. Further interviews with the Director of Nursing and a Nurse Practitioner confirmed that the physician's order was for 3 liters per minute and that administering a higher dose was not appropriate for a resident with COPD unless specifically ordered. The facility's policy on medication administration requires that medications, including oxygen, be administered exactly as prescribed by the physician. The failure to follow the physician's order resulted in the resident receiving a higher dose of oxygen than intended.