Failure to Administer Oxygen as Prescribed
Penalty
Summary
Facility staff failed to administer supplemental oxygen as prescribed for one resident with acute and chronic respiratory failure, chronic obstructive pulmonary disease, and chronic pulmonary edema. The resident's care plan and physician's orders specified that oxygen saturation should be maintained between 88% and 94%. However, review of the Medication Administration Records (MAR) revealed that on 66 out of 84 documented occasions, the resident's oxygen saturation was above 94% and the physician was not notified as required by the order. The Director of Nursing confirmed that staff did not follow the prescribed parameters for oxygen administration and failed to notify the physician when the resident's oxygen saturation exceeded the ordered range. The facility's policy required staff to verify and review physician orders for safe oxygen administration, but this was not adhered to in this case.