Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with asthma and chronic obstructive pulmonary disease (COPD) was not administered oxygen at the physician-ordered rate. The resident's care plan specified oxygen administration per physician orders, and a standing order required oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%. However, during two separate observations, the resident's oxygen concentrator was set at 5 liters per minute. The resident reported being unable to adjust the oxygen setting without staff assistance and denied making any changes to the regulator. Nursing staff, including the nurse assigned to the resident, had not verified the oxygen setting prior to the observations and acknowledged that the oxygen rate should have been checked at the beginning of the shift. Interviews with the nurse, unit manager, nurse practitioner, DON, and administrator confirmed that staff were expected to ensure oxygen was set at the ordered rate and to follow physician orders. The failure to verify and maintain the correct oxygen flow rate as prescribed led to the deficiency.