Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure and hypoxia, who was dependent for all activities of daily living and had severely impaired cognitive skills, did not receive oxygen at the physician-ordered rate. The resident was admitted with orders for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Multiple observations over four consecutive days revealed that the oxygen concentrator was set at 1 LPM instead of the prescribed 2 LPM, despite the resident's care plan and physician's orders specifying the correct rate. Interviews with nursing staff and the DON confirmed that the oxygen flow rate was not checked as required during initial assessments, and the staff member responsible for the resident during the observed period did not recall verifying the flow rate on any of those days. The DON and Administrator both stated that staff are expected to follow physician orders for oxygen administration, and the NP confirmed that an active order specifying the flow rate must be followed. The failure to ensure the resident received oxygen at the prescribed rate was directly observed and acknowledged by facility staff.