Oxygen Therapy Not Administered per Physician Order
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) was not administered oxygen therapy in accordance with the physician's order. The physician's order specified that oxygen should be administered at 3 liters per minute via nasal cannula continuously every shift. However, during an observation, the resident was found to be receiving oxygen at 2.5 liters per minute, as confirmed by both the resident and a licensed nurse. The nurse initially read the oxygen concentrator flow meter as 3 liters per minute while standing, but upon rechecking at eye level, confirmed it was actually set at 2.5 liters per minute and then adjusted it to the correct level. The resident's care plan indicated the need for oxygen therapy to maintain oxygen saturation at or above 92%, with an intervention to administer oxygen at 2 liters per minute via nasal cannula. The discrepancy between the physician's order, the care plan, and the actual administration of oxygen was noted during the survey. The Director of Nursing confirmed that the oxygen gauge should be read at eye level, highlighting a lapse in proper procedure that led to the resident not receiving oxygen as ordered.