Oxygen Therapy Not Administered per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with a history of asthma, anxiety disorder, acute and chronic respiratory failure with hypoxia, and dependence on supplemental oxygen was not provided respiratory care in accordance with physician orders. The resident's care plan and physician orders specified oxygen administration at 3 liters per minute (L/min) via nasal cannula. However, multiple observations by the surveyor over several days revealed that the resident's oxygen was consistently set at 4 L/min, contrary to the prescribed amount. The resident was observed in her room and in a wheelchair, receiving oxygen at the incorrect flow rate on several occasions. Interviews with the resident and staff confirmed the discrepancy, with the resident stating she believed she was receiving 3 L/min and an LPN acknowledging the order was for 3 L/min. The LPN adjusted the oxygen to the correct setting only after being informed by the surveyor. No explanation was provided by the facility as to why the oxygen was not administered according to the physician's orders, and the deviation from the prescribed flow rate persisted over multiple shifts before being corrected.