Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
A deficiency was identified when a resident with diagnoses including shortness of breath and congestive heart failure was observed receiving oxygen therapy at a rate of 3 liters per minute (lpm) via nasal cannula, despite an active physician order specifying oxygen at 2 lpm continuously. The surveyor observed the resident on two separate occasions receiving oxygen at 3 lpm, and upon inquiry, an LPN confirmed the order was for 2 lpm and adjusted the flow rate accordingly. The resident's care plan also indicated that oxygen should be administered per physician order. A review of the resident's medical record confirmed the physician's order for 2 lpm oxygen via nasal cannula, and the facility's policy on oxygen administration stated to follow the ordered rate. The discrepancy between the ordered and administered oxygen flow rate was not identified or corrected until brought to the attention of staff by the surveyor. No additional information or clarification was provided by facility leadership during the surveyor's interview.