Failure to Ensure Proper Functioning and Use of Oxygen Concentrator
Penalty
Summary
A resident with a history of COPD, chronic respiratory failure, pneumonia, and nicotine dependence required continuous oxygen therapy to maintain oxygen saturation above 90%, as ordered by the attending physician. The most recent physician order specified oxygen at 2 liters per minute (l/m) at all times. The resident was moderately cognitively impaired and dependent on staff for several activities of daily living. The care plan and medical records indicated the need for continuous oxygen, but did not specify the exact setting in the care plan. On multiple occasions, the resident's oxygen concentrator was observed to be malfunctioning, as indicated by a yellow warning light on the device, which, according to the manufacturer's manual, signified that the machine was producing substandard oxygen purity and required immediate attention. Despite this warning, the resident continued to receive oxygen from the malfunctioning concentrator, and the device was set at 4 l/m, which was not in accordance with the most recent physician order of 2 l/m. The resident's oxygen saturation levels fluctuated, with some readings below the target threshold, and the resident exhibited signs of respiratory distress, including rapid, shallow breathing and difficulty speaking. Staff interviews confirmed awareness of the malfunctioning equipment and the discrepancy between the ordered and delivered oxygen flow rates. The oxygen concentrator was not replaced until after the issue was brought to the attention of the Director of Nursing. The resident's condition improved after the concentrator was exchanged for a functioning device, but the deficiency centered on the failure to ensure the oxygen concentrator was operating properly and that oxygen was administered according to the provider's orders.