Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure was not administered oxygen at the physician-ordered rate. The resident had a documented order for continuous oxygen via nasal cannula at 2 liters per minute, and the care plan reflected this intervention. However, during two separate observations, the oxygen concentrator was set at 3 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by a nurse who was responsible for the resident's care during the observed shifts, who admitted she had not checked the oxygen setting earlier that morning. Interviews with facility staff, including the nurse practitioner and the Director of Nursing, confirmed that the expectation was for nurses to ensure oxygen was set at the ordered rate and to contact the provider if adjustments were needed. The Director of Nursing stated that nurses should verify oxygen rates when assuming care and throughout their shift. The administrator also confirmed the expectation that nurses monitor oxygen settings to ensure compliance with provider orders. The failure to administer oxygen at the prescribed rate was identified through record review, direct observation, and staff interviews.