Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypercapnia was not provided respiratory care consistent with professional standards. The resident was readmitted to the facility with a care plan and physician's order specifying oxygen therapy at 2 liters per minute (LPM). However, surveyor observations on multiple occasions revealed that the resident was receiving oxygen at approximately 3.5 LPM, which was not in accordance with the prescribed order. Staff interviews confirmed the discrepancy, with a registered nurse acknowledging that the resident was not receiving the ordered amount of oxygen. The Director of Nursing Services also indicated that the expectation was for the resident to receive oxygen at the ordered rate. Laboratory results showed the resident had elevated carbon dioxide levels, which can be associated with both COPD and supplemental oxygen use. The failure to administer oxygen as ordered constituted a lack of adherence to professional standards of respiratory care.