Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of respiratory failure, hypoxia, pneumonia, and congestive heart failure was not administered oxygen therapy in accordance with the physician's orders. The resident's care plan specified continuous oxygen via nasal cannula at 2 liters per minute (LPM). However, multiple observations revealed that the oxygen concentrator was set below the prescribed 2 LPM, with flow rates recorded between 1.5 and 2 LPM. Staff interviews confirmed that the oxygen flow was not consistently set to the ordered rate, and the concentrator's marker was not properly aligned with the prescribed setting. Facility policy required nurses to initiate oxygen use as ordered, label tubing, and ensure orders for filter cleaning and humidification were entered into the system, as well as to check oxygen saturations as ordered by the physician. Despite these requirements, staff did not ensure the oxygen concentrator was set to the correct flow rate. Both the ADON and DON acknowledged that the oxygen was not set according to the physician's order and that nurses are responsible for monitoring and adjusting concentrators as needed.