Failure to Follow Physician's Order for Oxygen Administration
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Facility staff failed to follow a physician's order for oxygen administration for Resident #52, who had a history of chronic obstructive pulmonary disease (COPD) and lung cancer and was assessed as having intact cognition. The physician's order specified that oxygen should be administered at 4 liters per minute (lpm) via nasal cannula every shift, with removal only for bathing and daily care. However, observations on two separate occasions revealed that the resident was receiving oxygen at lower rates—3.4 lpm and 3 lpm, respectively. Both the Clinical Care Coordinator/LPN and the Director of Nursing confirmed that the oxygen was not administered at the prescribed rate, acknowledging that it should have been set at 4 lpm as ordered.