Failure to Follow Physician Order for Oxygen Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy according to the physician’s ordered flow rate for a resident with chronic respiratory conditions. The resident’s face sheet showed diagnoses including COPD, and the quarterly MDS documented that the resident was cognitively intact with a BIMS score of 13 and was receiving oxygen therapy. The resident’s care plan, dated 07/22/24, identified altered respiratory status related to chronic respiratory failure, COPD, CHF, and sleep apnea, with an intervention specifying oxygen as ordered. Physician orders in the EMR, dated 06/30/25, directed oxygen at 4 LPM via nasal cannula. Despite this order, surveyor observations on three separate dates found the resident in bed with an oxygen concentrator delivering 4.5 LPM via nasal cannula. The concentrator was located approximately two feet from the left side of the bed, and the resident was not able to get out of bed to adjust the concentrator independently, as confirmed by the RN/Unit Manager. During an interview, the RN/Unit Manager verified that the oxygen was set at 4.5 LPM and that the physician’s order specified 4 LPM. The DON also confirmed that the order for the resident’s oxygen was 4 LPM. The facility’s policy on Nasal Oxygen Administration required staff to read and note the physician’s written order for nasal oxygen with the stated flow rate in liters per minute, which was not followed in this case.
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