Failure to Follow Physician's Order for Oxygen Administration
Penalty
No penalty information released
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Summary
A deficiency was identified when a resident with a diagnosis of acute and chronic respiratory failure with hypoxia was observed receiving oxygen at a rate higher than the physician's prescribed order. Multiple observations over several days showed the resident's oxygen concentrator set at 2.5 to 3 liters per minute, despite the physician's order specifying 2 liters per minute. The resident's care plan noted a tendency to remove oxygen at times, but during the survey period, the resident was consistently observed with the nasal cannula in place. The discrepancy between the ordered and administered oxygen flow rate was confirmed through record review and direct observation.