Failure to Administer Oxygen per Physician Order
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident with acute and chronic respiratory failure, hypoxia, anxiety, congestive heart failure, and pneumonia. The physician had ordered oxygen via nasal cannula at two to three liters per minute every shift, and the resident's care plan included interventions to provide oxygen as ordered and to monitor oxygen saturation. However, during multiple observations, the resident's oxygen was found to be set at four liters per minute, exceeding the prescribed amount. This was confirmed by an LPN, who acknowledged that the oxygen flow rate did not match the physician's order. The facility's policy required oxygen to be administered only as ordered by a physician, except in emergencies.