Failure to Ensure Nurse Competency in Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skill sets to care for residents as identified through assessments and care plans. Specifically, a nurse (RN A) was not trained in the use of a non-rebreather mask for oxygen therapy and was unfamiliar with the required oxygen flow parameters and when to discontinue its use. This resulted in a resident with multiple complex medical conditions, including COPD, being placed on a non-rebreather mask at an incorrect oxygen flow rate without appropriate physician orders or documentation in the care plan. The resident in question was an elderly female with diagnoses including dementia, myxedema coma, heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and COPD. She was dependent on staff for all activities of daily living and required oxygen therapy as part of her care. The care plan specified oxygen via nasal cannula at 2-4 L/min but did not include the use of a non-rebreather mask. Despite this, RN A placed the resident on a non-rebreather mask at 5 L/min following a hospice nurse's suggestion, although the standard for non-rebreather masks is a minimum of 10 L/min. RN A admitted to never having used a non-rebreather before and was not familiar with its proper use. Interviews revealed that the hospice nurse did not provide explicit orders to continue the non-rebreather mask and was unaware it was left on the resident for an extended period. Additionally, a hospice CNA reported finding the resident without oxygen or with an empty oxygen tank on several occasions and had to notify facility staff. The Director of Nursing confirmed that non-rebreather masks should be set at 10-15 L/min and would not expect them to be used at lower rates. The facility's policy required staff to be familiar with oxygen administration methods, but this was not followed in the resident's care.