Failure to Administer Oxygen at Physician-Ordered Setting
Penalty
Summary
A resident with multiple diagnoses, including abnormal lung findings, dementia, congestive heart failure, chronic kidney disease, muscle wasting, type 2 diabetes, dysphagia, and hypertension, was admitted with a physician order for oxygen therapy at 2 liters per minute (LPM) via nasal cannula. The resident's care plan included interventions to address the risk for altered respiratory status, specifying that oxygen should be administered as ordered. During an observation, the oxygen concentrator was found set at 3 LPM instead of the ordered 2 LPM. The resident was in bed with the head of the bed slightly elevated and showed no signs of respiratory distress at the time of observation. The resident was unaware of the correct oxygen setting and did not recall the nurse checking the oxygen machine, although he stated the nurse had been in his room earlier. The assigned nurse confirmed the oxygen was set at 3 LPM and acknowledged the physician's order was for 2 LPM. She reported having checked the setting earlier in her shift and was unsure who may have changed it, noting the resident had received a nebulizer treatment that morning. The DON stated that nurses are responsible for checking oxygen settings once per shift and following physician orders, but also revealed that the facility did not have a specific Oxygen Administration Policy. Facility policy on medication administration required medications to be given as ordered.