Failure to Ensure Proper Placement of Nasal Cannula for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of sepsis, acute respiratory failure, and immunodeficiency, who lacked decision-making capacity, did not receive oxygen therapy as ordered. The physician's orders specified oxygen via nasal cannula at 1 liter per minute, with titration to maintain oxygen saturation at or above 95%. During an observation, the resident was found with the nasal cannula prongs not inserted in the nostrils while receiving oxygen, and was noted to be moving around and hyperventilating. A registered nurse was observed correcting the placement of the nasal cannula and confirmed that the prongs should be in the nostrils to deliver oxygen as ordered. The Director of Nursing also stated that the nasal cannula should be properly placed in the nostrils for effective oxygen administration. Review of the facility's policy confirmed that the equipment and placement depend on the delivery system ordered, such as a nasal cannula for oxygen through the nostrils.