Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary care and services for respiratory care in accordance with professional standards for a resident requiring continuous oxygen therapy. According to the physician's order, the resident was to receive continuous oxygen at 2 liters per minute via nasal cannula due to diagnoses including COPD with acute exacerbation, other lung disorders, dependence on supplemental oxygen, and dyspnea. The resident's care plan also specified continuous oxygen at all times. However, multiple observations revealed that the resident was receiving oxygen at 3.5 liters per minute, which was not in accordance with the physician's order. Additionally, the resident reported that no staff checked the oxygen flow rate to ensure it matched the prescribed amount. The facility's policy required verification of physician orders and ongoing assessment before and during oxygen administration, but there was no evidence that staff were monitoring or adjusting the oxygen flow as ordered. This failure to follow physician orders and facility policy resulted in the resident receiving a higher oxygen flow rate than prescribed.