Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician-ordered flow rate for one resident with a history of chronic respiratory conditions, including COPD and chronic respiratory failure. The resident was admitted with an order for oxygen to be provided at 3 liters per minute (L/min) via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set at 2 L/min on one occasion and at 2.5 L/min on another, both below the prescribed rate. Staff interviews confirmed that the oxygen should have been set at 3 L/min, and the Director of Nursing stated that nurses were responsible for verifying that oxygen was administered at the ordered flow rate. The deficiency was further evidenced by direct observation of staff actions, including a CNA placing the oxygen cannula on the resident and the concentrator being set incorrectly, as well as a registered nurse acknowledging the discrepancy between the order and the actual setting. Facility policy required oxygen to be administered at the prescribed flow rate, but this was not followed for the resident in question, resulting in a failure to provide safe and appropriate respiratory care as ordered.