Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral palsy, epilepsy, congestive heart failure, muscle weakness, and diabetes mellitus, did not receive oxygen therapy as ordered by the physician. The resident's care plan and physician's order specified continuous oxygen administration at 3 liters per minute via nasal cannula. However, during observations on two separate days, the resident was found receiving oxygen at only 2 liters per minute, both in the dining room with a portable oxygen canister and in their room with an oxygen concentrator. Despite the Medication Administration Record being signed by nursing staff to indicate that the oxygen was administered as ordered, direct observation and staff interviews confirmed the oxygen flow rate was set incorrectly at 2 liters per minute instead of the prescribed 3 liters per minute. The LPN acknowledged the discrepancy, and the Director of Nursing confirmed that oxygen is expected to be administered as ordered by the physician.