Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for a resident with a history of respiratory failure, diabetes mellitus, and obesity. The resident was admitted and later readmitted to the facility, and their Minimum Data Set indicated they had intact cognition but required moderate to total assistance with activities of daily living. The resident was documented as receiving oxygen therapy. During an observation and record review, it was found that the resident's oxygen was set at 1.5 liters per minute (LPM), while the physician's order specified continuous oxygen at 2-4 LPM every shift. The Director of Staff Development confirmed that the oxygen flow rate did not match the physician's order and acknowledged the risk of desaturation. The Director of Nursing also stated that licensed nurses are expected to follow physician orders to ensure the prescribed oxygen flow rate is administered. Facility policy requires medications, including oxygen, to be administered as prescribed.