Failure to Follow Physician Order for Oxygen Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy in accordance with physician orders and professional standards of practice for one resident using supplemental oxygen. Facility policy and Lippincott Nursing Procedure require a practitioner’s order for oxygen therapy and that the oxygen flow rate be set at the amount specified in the order, with documentation of the rate of flow. The resident, admitted with diagnoses including pneumonia and acute respiratory failure, had a physician’s order dated 12/13/2025 for oxygen at 2 liters per minute as needed. Despite this, surveyor observations on multiple dates and times showed the resident receiving oxygen at 3 liters per minute instead of the ordered 2 liters per minute. During an observation and interview, an RN stated that the resident was receiving oxygen at 3 liters per minute and asserted there was an order for 3 liters per minute. Upon review of the electronic medical record at the surveyor’s request, the RN acknowledged that the actual order was for 2 liters per minute. The Unit Manager also acknowledged that the order indicated 2 liters, not 3 liters, as observed. Later the same day, after the facility had been informed by the surveyor that the oxygen flow rate was incorrect, the resident was again observed receiving 3 liters per minute. The Director of Nursing Services stated she would have expected the resident to receive oxygen at 2 liters per minute, as ordered.
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