Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy as prescribed for a resident with a history of pneumonia, heart failure, sleep apnea, and acute/chronic respiratory failure. The resident was admitted with physician orders specifying oxygen at 4 liters per minute (LPM) via nasal cannula while walking and 1 LPM while sitting or resting. However, multiple observations revealed that the resident was receiving oxygen at 2 or 3 LPM while at rest, rather than the ordered 1 LPM. The resident was cognitively intact, reported no shortness of breath, and stated that staff managed his oxygen settings. Nursing staff interviews confirmed that the resident was routinely placed on 2 LPM at rest and 4 LPM with exertion, with therapy staff having recently titrated the oxygen during therapy sessions. Upon review of the resident's orders, a nurse realized the prescribed amount at rest was 1 LPM, not 2 LPM as previously administered. The DON stated that nurses are responsible for ensuring the correct oxygen dose is delivered after reviewing orders each shift. The discrepancy between the physician's order and the oxygen administered at rest led to the deficiency.