Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide supplemental oxygen to a resident as ordered by the physician. The resident, who had multiple respiratory diagnoses including anoxic brain damage, MRSA pneumonia, COPD, asthma, emphysema, and both acute and chronic respiratory failure, was dependent on staff for all activities of daily living and was to receive continuous oxygen therapy at two liters per minute via nasal cannula. During observation, the resident was found lying in bed with the oxygen concentrator running, but the nasal cannula was on the floor and not in use, resulting in the resident not receiving oxygen as ordered. When the primary care LPN was questioned, she was initially unaware of the resident's oxygen order and did not address the misplaced nasal cannula. Upon review of the physician's orders, the LPN confirmed the need for continuous oxygen at two liters per minute. After reconnecting the oxygen tubing and cannula, it was discovered that the concentrator was set to 1.5 liters per minute, not the prescribed two liters. The facility's policy required staff to verify and follow physician orders for oxygen administration, which was not done in this instance.