Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician orders for three residents with chronic respiratory conditions. For one resident with chronic respiratory failure and hypoxia, the physician ordered continuous supplemental oxygen at 4 liters per minute (LPM) via nasal cannula. However, observation revealed the oxygen concentrator was set at 0 LPM while the resident was awake and upright, and the Director of Nursing confirmed the resident should have been receiving oxygen as ordered. Another resident with chronic obstructive pulmonary disease (COPD) had a physician's order for continuous oxygen at 3 LPM, but was observed with the flowmeter set at 2.5 LPM; this was confirmed by an LPN. A third resident, also with COPD, was prescribed continuous oxygen at 3 LPM but was observed with the concentrator set at 2 LPM, and the resident reported not feeling oxygen from the cannula, though not in distress. The DON confirmed the setting was incorrect. These findings were based on clinical record reviews, facility policy review, direct observations, and staff and resident interviews. The facility's policy requires licensed nurses to initiate and monitor oxygen therapy per physician orders, but in these cases, the prescribed flow rates were not maintained, resulting in deviations from the required oxygen administration for all three residents.