Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of shortness of breath, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD) was not provided oxygen therapy as ordered by the physician. The resident, who was cognitively intact, was observed lying in bed with a nasal cannula in place, but the oxygen concentrator was set to deliver 0 liters and was not running. The resident confirmed that they were supposed to be on 2 liters of oxygen. Upon further inspection, it was found that the concentrator was not plugged in, and there was no audible sound indicating it was operational. A nurse confirmed that the resident was supposed to be on oxygen and subsequently plugged in the concentrator. Record review showed a physician's order for continuous oxygen at 2 liters via nasal cannula. During an interview, the respiratory therapist stated that the resident used oxygen for comfort but acknowledged that the order in the system was for continuous use and should have been followed. The failure to administer oxygen as ordered was not addressed until it was brought to staff attention during the survey.