Failure to Administer Oxygen Therapy at Physician-Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received oxygen therapy at the rate ordered by the physician. The resident, who had diagnoses including COPD, CHF, metabolic encephalopathy, and dementia, had a physician's order for continuous oxygen at 2L/min via nasal cannula. However, observations on multiple occasions revealed that the resident was receiving oxygen at higher rates, specifically 3.5L/min and 4L/min, rather than the ordered 2L/min. Nursing staff interviews confirmed that the oxygen settings were not consistently checked or maintained at the prescribed rate, and there was confusion among staff regarding the correct order, with one nurse incorrectly stating the order was for 2-3L/min. Record reviews showed that the oxygen therapy was documented as administered according to the order, but direct observation contradicted these records. The facility's policy required nurses to verify physician orders for oxygen flow rate and route, but this was not consistently followed. Staff interviews indicated a lack of awareness regarding the specific reasons for the oxygen order and the importance of adhering to the prescribed rate. The Director of Nursing acknowledged that orders must be followed and expected nurses to check oxygen settings at least once per shift, but this expectation was not met in practice.