Failure to Administer Physician-Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to provide respiratory services in accordance with professional standards of practice for a resident with a physician's order for supplemental oxygen at 3 liters per minute (LPM) via nasal cannula for chronic obstructive pulmonary disorder (COPD). Multiple observations over three consecutive days showed the resident receiving oxygen at lower flow rates than ordered, specifically at 1.5 LPM and 2 LPM, rather than the prescribed 3 LPM. These findings were confirmed by the Director of Nursing (DON) during the survey. The deficiency was identified through observation, record review, and staff interview, with documentation confirming the physician's order and the observed discrepancies in the oxygen flow rate provided to the resident.