Incorrect Oxygen Flow Rate Administered
Penalty
Summary
A resident with diagnoses including chronic obstructive pulmonary disease, hypertension, and chronic cough was observed on two occasions receiving oxygen via nasal cannula at a flow rate of 4 liters per minute (lpm), despite a physician's order specifying continuous oxygen at 2 lpm. The resident, who was cognitively intact, confirmed she was supposed to be on 2 lpm of oxygen. Review of the resident's medical record corroborated the physician's order for 2 lpm. During an interview, an LPN acknowledged the resident should be on 2 lpm, observed the concentrator set at 4 lpm, and adjusted it to the correct flow rate. The facility failed to ensure the resident received the necessary care and treatment by not providing the ordered oxygen flow rate.