Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and severe cognitive impairment was not provided respiratory care in accordance with physician orders and professional standards. The resident was dependent for all hygiene, dressing, and transfer needs, and had orders for oxygen therapy via nasal cannula at 3-4 L/min. During an observation, the resident's nasal cannula was found around his neck and not in use, and the oxygen concentrator was set at 10 L/min instead of the ordered 3 L/min. The resident did not appear to be in distress at the time of observation and denied any breathing difficulties. A nurse confirmed that the oxygen setting was incorrect and immediately adjusted it to the prescribed rate. The nurse also noted that the resident's family sometimes altered the oxygen setting, but she had not checked the setting after providing care earlier that day. The facility's policy requires nurses to administer and monitor oxygen therapy as ordered by the physician. Further observations showed the resident frequently removed his nasal cannula, and his oxygen saturation was within normal limits on room air. However, the failure to ensure the oxygen was set at the correct rate as ordered constituted a deficiency in providing safe and appropriate respiratory care.