Failure to Administer Oxygen per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of pneumonia, acute and chronic respiratory failure with hypoxia, and COPD was not provided oxygen therapy according to the physician's order. The resident's care plan and physician's order specified oxygen administration at 4 liters per minute (LPM) via nasal cannula. However, on the date of observation, the oxygen concentrator was set at 1 LPM while the resident was in bed. The resident reported that staff had previously set the oxygen at 4 LPM. During interviews, a CNA stated she believed the oxygen should be set at 2 LPM, based on instructions for another resident, and admitted she had not checked with the nurse regarding the correct setting. The CNA also stated she was supposed to verify the setting with the nurse but had not done so. Further observation and interview with an LVN confirmed the concentrator was set at 1 LPM, and the LVN acknowledged the risk of hypoxia if the setting was incorrect. The LVN stated that both nurses and other staff involved in care were responsible for ensuring the correct oxygen setting. The DON and Administrator both confirmed that the nurse was responsible for following the physician's order and communicating the correct flow rate to the CNA. Facility policy required verification of physician orders and correct oxygen administration, but the observed practice did not align with these requirements.