Failure to Provide Prescribed Oxygen Flow Rate for Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and multiple complex medical conditions, including traumatic brain injury, paraplegia, and dependence on supplementary oxygen, did not receive the prescribed dose of oxygen as ordered by the physician. The physician's order specified that the resident should receive cool air mist via trach collar continuously with oxygen bled in at 5 liters per minute (LPM). However, during multiple observations on different days, the oxygen concentrator was found to be set below the prescribed rate, at 4.0 LPM and 4.5 LPM, rather than the required 5.0 LPM. These findings were confirmed through direct observation, record review, and staff interview. The discrepancy between the physician's order and the actual oxygen delivery was verified by a registered nurse, who acknowledged that the concentrator was not set to the correct rate as ordered. The resident was observed asleep during one of the checks, and the incorrect oxygen flow persisted across several days before being identified and corrected.