Failure to Maintain Physician-Ordered Oxygen Flow Rate
Penalty
Summary
Facility staff failed to provide respiratory care and services as ordered for one resident with COPD and respiratory failure. The resident was admitted with these diagnoses and had a physician's order for oxygen therapy at a flow rate of two liters per minute via nasal cannula. Multiple observations on different days revealed that the oxygen flow rate being delivered to the resident was between two and three liters per minute, rather than the prescribed two liters per minute. The resident's care plan also specified that oxygen therapy should be administered at the ordered rate and device. Staff interviews confirmed that the correct method for reading the oxygen flow meter is to ensure the bottom of the float ball is on the prescribed liter line, as also indicated in the manufacturer's instructions and facility policy. Despite these guidelines, the oxygen flow rate was not maintained at the physician-ordered level during the observed periods. The deficiency was brought to the attention of facility administrative and nursing leadership, but no additional information was provided prior to the survey exit.