Hospice patient was placed on 70 percent fio2 via t-piece delivered at 15 l/min.Oxygen tubing was witnessed by nursing staff to pop off at venturi connection.This was replaced by staff.Patient was found with t-piece on chest and o2 disconnected from flow meter.Indicator ball noted to be floating at top of meter.Patient expired.Nurse, upon finding patient, reconnected oxygen and during assessment of patient for any vital signs, tubing again dislodged from flow meter.Flow meter was tested by biomedical department and found it to be delivering oxygen outside of manufacturer specification.At 15 l, the flow meter was delivering 20.14 l/min.Utilizing a different oxygen set up mirroring the patient set up in a controlled biomed environment, tubing connected to this flow meter again popped off at the venturi connection at 10 minutes of flow, and once replaced, regulator ball was witnessed to drift to the top of regulator.Once tubing replaced, the system popped off the tubing again at 20 minutes of flow.Ref mfr # 1419185-2018-00001.
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