Failure to Administer Oxygen at Physician-Ordered Flow Rates
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered at the correct flow rates as ordered by physicians for two residents. For one resident with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), repeated observations showed that oxygen was administered via nasal cannula at 1.5 liters per minute, while the physician's order specified 2 liters per minute as needed to maintain oxygen saturation above 90 percent. The resident's medical record confirmed the order, and the DON acknowledged the flow rate should have been set at 2 liters. For another resident with COPD and chest pain, observations revealed that oxygen was administered at 4 liters per minute, while the current physician's order required continuous oxygen at 3 liters per minute via nasal cannula. The care plan also directed staff to administer oxygen per the physician's order. The DON confirmed that the flow rate should have been set at 3 liters. Both residents had moderate cognitive impairment and were observed multiple times receiving oxygen at incorrect flow rates, contrary to their physician's orders.