Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician's orders for oxygen administration for one resident. According to facility policy, oxygen therapy must be administered as ordered by a physician, and licensed nurses are expected to follow these orders. Medical record review showed that the resident, who had diagnoses including anemia, heart failure, dementia, and anxiety disorder, was admitted with a physician's order for oxygen via nasal cannula at 2 liters per minute as needed. The Medication Administration Record indicated that oxygen was administered daily at the ordered rate. However, observations on two separate occasions revealed that the resident was receiving oxygen at higher flow rates than prescribed, with the concentrator set at 3 liters per minute and later at 2.5 liters per minute. During an interview, the DON confirmed that the oxygen flow rate was not set according to the physician's order and acknowledged that staff should have followed the prescribed rate. This discrepancy between the physician's order and the actual administration of oxygen constituted a failure to provide safe and appropriate respiratory care as required by facility policy.