Failure to Administer Oxygen as Ordered
Penalty
Fine: $25,475
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
Surveyors determined that the facility failed to administer oxygen therapy as ordered by the physician for a resident with respiratory failure. The physician's order specified continuous oxygen at 5 liters per minute via nasal cannula. However, on multiple occasions, the resident was observed receiving only 4 liters per minute. These observations were confirmed by two LPNs and a second surveyor, and the discrepancy between the ordered and administered oxygen flow rates was acknowledged by staff. The resident's medical record and treatment administration record both reflected the physician's order for 5 liters, but the actual administration did not match the prescribed amount.