Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and a physician's order for continuous oxygen at 2 liters via nasal cannula was observed multiple times throughout the day with an empty portable oxygen tank. The resident, who required oxygen due to asthma and reported episodes of wheezing, was seen in her wheelchair both in her room and on the patio with the nasal cannula in place but no oxygen being delivered, as the tank was empty. This was confirmed by several staff members, including CNAs and a registered nurse, who acknowledged that the oxygen tank had been empty since the morning and had not been replaced as required by the resident's care plan and physician's orders. Interviews with staff revealed confusion regarding responsibilities for changing and initiating portable oxygen tanks, with CNAs stating they typically changed the tanks and nurses indicating that only licensed staff should initiate oxygen therapy. The facility's policy specified that only physicians, RNs, LPNs, and respiratory therapists are authorized to initiate oxygen therapy. Despite the availability of full oxygen tanks in storage, the resident did not receive the ordered continuous oxygen therapy for an extended period, as evidenced by direct observation and staff interviews.