Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure, hypoxia, and other significant health conditions was not provided oxygen therapy as ordered by the physician. The resident had orders for continuous oxygen via nasal cannula at 2 to 4 liters per minute to maintain oxygen saturation above 90%. Multiple observations revealed that the resident's oxygen tank was not turned on while the nasal cannula was in place, and the resident was found with rapid, labored breathing and an oxygen saturation as low as 69%. Staff confirmed the oxygen was not on and that the resident required continuous oxygen. The oxygen was subsequently turned on and the flow rate increased, resulting in improved oxygen saturation. The resident's electronic medical record did not contain documentation of the incident or the drop in oxygen saturation below 90%. Additionally, a safety event was recorded as a medication incident, but lacked vital signs and progress notes. Interviews with staff indicated that nursing assistants were responsible for switching oxygen tanks, while nurses were responsible for monitoring oxygen saturation and flow rates. The nurse manager and DON confirmed that there was no documentation of the incident in the medical record, despite facility policy requiring oxygen to be administered per order.