Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident. Specifically, the resident had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, multiple observations over several days showed the resident receiving oxygen at 3 liters per minute via a face mask, which did not match the physician's order regarding both the delivery method and the flow rate. The facility's policy on oxygen administration requires verification and adherence to physician orders, including the specific device and flow rate. The resident involved had a history of chronic diastolic heart failure, primary pulmonary hypertension, and sleep apnea, and was cognitively intact according to the most recent assessment. Despite the care plan and physician's orders specifying oxygen administration via nasal cannula at a set rate, staff were observed providing oxygen through a different device and at a higher flow rate. Interviews with nursing staff and the Director of Nurses confirmed that oxygen should be administered exactly as ordered by the physician, both in terms of device and flow rate.