Failure to Maintain Prescribed Oxygen Levels for Resident
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident reviewed for respiratory care. The resident, who was severely cognitively impaired and aphasic, had a physician's order for oxygen to be administered at 2 liters per minute via nasal cannula as needed for wheezing or shortness of breath. However, during observations, the oxygen concentrator was found running at incorrect levels of 3 liters per minute and 1.5 liters per minute on separate occasions, contrary to the physician's order. Licensed Practical Nurse (LPN) #6 confirmed that oxygen levels were set by licensed staff according to physician orders and were checked at the start of each shift. The LPN was unaware of why the concentrator was observed at incorrect settings and suggested that a Certified Nurse Aide might have accidentally adjusted the dial during care. Despite the LPN's assertion that the oxygen was set at 2 liters per minute daily, the observations indicated a failure to maintain the prescribed oxygen level, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified - Upon notification of this deficiency, resident #29's oxygen was immediately adjusted to the prescribed 2L/min. - An assessment revealed that resident #29 suffered no ill effects as a result of the deficient practice. - Resident #29 will be seen by the MD/NP for possible discontinuation of his oxygen therapy. - LPN #6 was provided re-education on the importance of ensuring that residents' oxygen devices were set to the recommendations ordered by the MD/NP. - Nurses to review and sign the flow of oxygen each shift. Residents at Risk - An audit of all residents with oxygen therapy was conducted to identify any other resident that may have been affected by this deficiency, and none were identified. - While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes - The facility reviewed Policy and Procedure Oxygen Therapy- Face Mask and Canula; no revision was needed. - Nursing staff to be in-service on the policy and procedure Oxygen Therapy- Face Mask and Canula. - The DON developed an audit tool to ensure the oxygen flow matched the doctor's order. The audit will include the residents who are on oxygen, whether nurses sign off that the correct flow is being given, and if there is a physician order [REDACTED]. Monitoring of Corrective Actions - The Director of Nursing or Designee will conduct audits daily x2 weeks, then weekly x 4 weeks, then monthly x 3 months. Any issues will be addressed immediately and reported to the administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. - The QAPI Committee will determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025