Failure to Administer Oxygen at Physician-Ordered Rate
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered at the physician-prescribed rate for a resident who required supplemental oxygen. According to facility policy, oxygen orders must specify the required liter flow, and staff are expected to administer oxygen as ordered. The resident in question had a history of heart failure, heart disease, and dependence on supplemental oxygen, and was assessed as having moderate cognitive impairment. The care plan and physician orders specified oxygen at 2 liters per minute (LPM) via nasal cannula as needed, with instructions to monitor oxygen saturation and notify the physician if levels dropped below 90%. Multiple observations over two days revealed that the resident consistently received oxygen at 1.5 LPM instead of the prescribed 2 LPM. Both the resident and staff, including an LPN and the Interim DON, confirmed that the oxygen was not set at the ordered rate. The nurse practitioner acknowledged that, regardless of perceived risk, oxygen therapy should be administered at the rate ordered by the medical provider. The deficiency was identified through policy review, medical record review, direct observation, and staff interviews.