Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
Richland Nursing and Rehab was found to be non-compliant with the requirement for respiratory care as outlined in 42 CFR Part 483.25(i). The deficiency was identified during an abbreviated complaint survey, where it was observed that the facility failed to ensure that oxygen was provided as ordered by the physician for a resident. The resident, who was severely cognitively impaired and had a history of congestive heart failure and pneumonia, was supposed to receive oxygen at zero to four liters per minute to maintain an oxygen saturation of 90 percent or more. However, during an observation, it was noted that the resident's oxygen was removed by two nurse aides during a transfer and was not reapplied, leading to a drop in the resident's oxygen saturation to 87 percent. Interviews with the nurse aides confirmed that the oxygen was not reapplied after the transfer, which was acknowledged as an oversight. The Director of Nursing also confirmed that the resident should have been provided with oxygen therapy as ordered. This incident highlights a failure in adhering to the facility's policy regarding safe oxygen administration, which required verification of the physician's order and proper application of oxygen therapy.
Plan Of Correction
1. Licensed Practical Nurse applied oxygen to Resident 3 and checked Resident's 3 oxygen saturation (measurement of the percentage of oxygen-rich hemoglobin in arterial blood) using a pulse oximeter (a device which measures the percentage of oxygen-rich hemoglobin in arterial blood) which showed Resident 3's oxygen saturation was at 94% on 2 liters of oxygen which is in line with her physician's order of her blood oxygen saturation being maintained at 90% or above. 2. At the time that it was noted that Resident 3's oxygen had not been properly reapplied post mechanical lift transfer, Admissions Coordinator, a licensed nurse, performed a set of nursing rounds to ensure other Residents ordered oxygen had it properly applied. No other Residents found to be missing their oxygen placement. 3. Education will be provided to Certified Nurses Aides to ensure that oxygen is properly reapplied to Residents after necessary removal for care tasks. 4. Licensed Practical Nurses will audit, per shift, Residents who are ordered to have oxygen to ensure that it is in place. Director of Nursing, or designee, will review three Residents per shift three times a week for two weeks, then monthly as needed, to ensure audits are being properly completed. Results will be reviewed with the Quality Assurance Performance Improvement committee.