Failure to Provide Oxygen Per Physician's Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, diabetes, and hypertension, who had a physician's order for oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath, did not receive oxygen as ordered. The facility's policy requires verification and adherence to physician's orders for oxygen administration. On the day of the incident, the resident was observed with supplemental oxygen in place and the concentrator set correctly at 2 LPM. However, an activities assistant removed the resident's nasal cannula and assisted the resident to an activity without reapplying the oxygen. The resident remained without oxygen until returning to their room over an hour later. Both the activities assistant and a licensed practical nurse confirmed that the resident did not have oxygen during this period and that the oxygen should have remained in place at all times, as per the physician's order.