Failure to Administer Oxygen Therapy per Physician Orders for Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and a history of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and heart failure did not receive oxygen therapy as ordered by the physician. The resident's care plan and physician's orders specified oxygen administration at 4-6 liters per minute (LPM) via an oxygen concentrator through the tracheostomy, and the air compressor was to be set at 60 PSI. However, during an observation, the resident was found receiving oxygen at 8 LPM and the air compressor was set at 40 PSI, both of which were inconsistent with the physician's orders. Licensed vocational nurses (LVNs) involved in the resident's care confirmed upon review that the oxygen and air compressor settings were incorrect and subsequently adjusted them to the ordered levels. The resident's oxygen saturation was checked and found to be 94% at the time of correction. The facility's policy on oxygen administration required verification and adherence to physician orders, which was not followed in this instance, resulting in the deficiency.