Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not administering oxygen at the correct dose for a resident with multiple chronic conditions, including heart failure, asthma, and sleep apnea. The resident had a physician's order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation at or above 90% and/or for shortness of breath. However, observations on multiple occasions showed the resident receiving oxygen at 4.5 liters per minute, which was not consistent with the physician's order. The resident's care plan did not address oxygen therapy, and staff interviews revealed a lack of awareness and monitoring of the oxygen flow rate being delivered. Staff interviews indicated that it was not common practice to administer oxygen at 4.5 liters per minute, and there was confusion among staff regarding the appropriate response to changes in the resident's respiratory status. The LVN responsible for the resident's care admitted to not checking the oxygen concentrator settings, and the DON acknowledged that setting the oxygen too high could have negative outcomes. The facility's policy required verification of a physician's order for oxygen administration, but this was not followed, resulting in the resident receiving a higher dose of oxygen than prescribed.