Failure to Ensure Adequate Oxygen Supply for Resident with COPD
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with Chronic Obstructive Pulmonary Disease (COPD), as required by professional standards and the resident's care plan. The resident had a physician's order for oxygen therapy at 2 liters per minute via a nasal cannula as needed for shortness of breath. During an observation, the resident was found attempting to use an empty oxygen tank, resulting in low oxygen saturation levels between 88 to 91 percent, which is below the normal range. The Director of Nursing Services confirmed the tank was empty and replaced it, which improved the resident's oxygen saturation level. The deficiency was further highlighted by the facility's Oxygen Administration Policy, which did not specify who was responsible for monitoring the oxygen tanks. Interviews with staff revealed that the resident had been using an oxygen tank due to a broken concentrator, and the tank was not checked regularly to ensure it had sufficient oxygen. A Licensed Practical Nurse admitted to not checking the tank after 9:00 AM, despite knowing it was only a quarter full. The Nurse Practitioner emphasized the importance of following physician orders for oxygen therapy, especially given the resident's significant COPD diagnosis.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #7’s oxygen tank was immediately replaced with an oxygen concentrator by the DNS on 2/12/25. Resident #7’s oxygen saturation level was checked by using pulse oximetry and was between 88-92% (the resident has a [DIAGNOSES REDACTED]. Licensed Practical Nurse #4 was educated to monitor oxygen tank levels. She was educated that tanks below ? of a tank should be replaced with a new tank if an oxygen concentrator is not available. LPN #4 was also educated that residents who receive oxygen therapy should have oxygen concentrators placed in their rooms, if available, for their use while in their room. II. All residents with orders for oxygen therapy have the potential to be affected by the same deficient practice. On this date, 3/10/25, there are a total number of 15 out of 223 residents who currently have orders for oxygen. All residents who receive oxygen in their rooms have been provided with an oxygen concentrator. III. The Oxygen Administration policy was reviewed and revised on 3/10/25 by the DNS, Medical Director, and Administrator. The revision includes: 1. licensed nursing staff is responsible to monitor oxygen tanks; 2. oxygen concentrators will be provided in resident rooms, if available, for residents receiving oxygen therapy. All licensed nursing staff will be educated by the Staff Educator on the revision of the Oxygen Administration policy regarding oxygen tank replacement if at a ? of a tank and to provide oxygen concentrators in resident rooms if available to residents receiving oxygen therapy. All licensed nurses will complete an Oxygen Administration competency post education. The Unit Manager and/or designee will round weekly to ensure residents with oxygen administration orders have an oxygen concentrator in their room, if available. IV. 5-7 residents who have oxygen administration orders will be audited to ensure the oxygen tank in use is above a ? of a tank and/or an oxygen concentrator is available bedside by the Unit Manager and/or designee weekly for one month and monthly for 6 months thereafter. Findings will be brought to the DNS weekly and then brought to QAPI monthly for review and discussion by the DNS and/or designee. V. The Director of Nursing will be responsible for compliance.