Failure to Administer Oxygen as Ordered
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), respiratory failure, urinary tract infection, dysphagia following cerebral infarction, and type 2 diabetes mellitus was admitted and readmitted to the facility. The resident's care plan specified the use of oxygen therapy, with a goal to remain free from adverse effects and interventions to provide oxygen as ordered, monitor oxygen saturation, and check the rate of oxygen flow every shift. The physician's order directed that oxygen be administered at 2 liters per minute (L/min) via nasal cannula, with titration up to 3 L/min if oxygen saturation fell below 92%. Despite these orders, observations on two separate occasions found the resident receiving oxygen at 3 L/min via nasal cannula, without documentation that the oxygen saturation was below 92% to warrant the increased flow. A registered nurse confirmed that the physician's order was for 2 L/min and acknowledged the risk of over-oxygenation. The facility's policy on medication reconciliation emphasized the importance of accurate medication dosages upon admission or readmission, but the resident was not administered oxygen according to the prescribed amount.