Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of chronic obstructive pulmonary disease (COPD) did not receive supplemental oxygen as ordered by the physician. The physician's order specified that the resident should receive oxygen at 3 liters per minute via nasal cannula every shift for shortness of breath. However, during an observation, the resident was found with the oxygen concentrator set at 2 liters per minute instead of the prescribed 3 liters per minute. The resident was unaware that the oxygen flow was set incorrectly and did not know who had adjusted it. A licensed nurse confirmed the physician's order for 3 liters per minute and, upon joint observation, verified that the concentrator was set at 2 liters per minute before adjusting it to the correct setting. This failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and the facility's policy on oxygen administration.