Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
A resident with chronic respiratory failure and chronic obstructive pulmonary disease was admitted to the facility with a physician's order for oxygen via nasal cannula at three liters per minute (LPM) as needed for shortness of breath, with the option to remove if breathing was comfortable. Despite this order, multiple entries in the Oxygen Saturations Summary Report documented that the resident received oxygen at two LPM on several occasions. Observations confirmed that the resident's oxygen concentrator was set to two LPM during multiple checks, and the resident reported wearing oxygen continuously and experiencing difficulty breathing. The resident also stated that they did not adjust the oxygen flow themselves and relied on facility staff for administration. Interviews with an LPN and the Interim Director of Nursing (DON) confirmed that the clinical record did not include an order for oxygen titration and that the expectation was for medications, including oxygen, to be administered at the correct dose as prescribed. The DON acknowledged that administering oxygen at an incorrect dose constituted a medication error. Facility policy required nurses to ensure the right dose when administering medications. The deficiency was identified through observation, interview, and record review, showing that the resident did not consistently receive oxygen at the prescribed rate.