Failure to Administer Oxygen at Physician-Ordered Setting
Penalty
Summary
A deficiency occurred when a resident with pulmonary fibrosis and muscle weakness, who required oxygen therapy for shortness of breath, did not receive oxygen at the physician-ordered setting. The resident's care plan and physician order specified oxygen at 2 liters per minute via nasal cannula. However, during an observation, the oxygen concentrator was set at 1.5 liters per minute. 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 nurse assigned to the resident confirmed the oxygen setting was incorrect and stated it should have been at 2 liters per minute as ordered. She reported checking the settings at the beginning of her shift but was unsure who might have changed it. The nurse also stated that she typically checks the oxygen once a day and as needed. The DON indicated that nurses are responsible for checking oxygen settings once per shift and are expected to follow physician orders. Facility policy requires that oxygen therapy be administered as ordered by a physician, with the method and amount determined by the resident's condition and reflected in the physician order.