Failure to Ensure Adequate Oxygen Supply During Resident Outing
Penalty
Summary
A deficiency occurred when a resident who required continuous oxygen therapy was not provided with adequate respiratory care during a community appointment. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, chronic respiratory failure, and chronic bronchitis, was sent to an outpatient appointment with a portable oxygen tank. Although the tank was reportedly full and set to 2 liters per minute before departure, the resident ran out of oxygen while at the appointment. The resident began experiencing shortness of breath and chest pain, prompting clinic staff to call 911, and the resident was subsequently transported to the hospital. The resident's care plan specified the need for continuous oxygen therapy, including interventions such as providing a portable oxygen apparatus, ensuring an extra tank for appointments, and monitoring for signs of respiratory distress. On the day of the incident, the resident was prepared for the appointment early in the morning and waited for transportation while using the portable oxygen tank. Staff interviews indicated that the appointment lasted longer than expected, and the resident may have used a significant portion of the oxygen supply while waiting at the facility and during transport. The staff did not send an extra oxygen tank, despite the potential for an extended appointment duration. Interviews with staff revealed that while nurses were responsible for checking and ensuring full oxygen tanks before appointments, there was a lack of clarity regarding the responsibility for monitoring oxygen levels during outings and ensuring adequate supply for longer appointments. The facility did not have a specific policy regarding portable oxygen tanks for community appointments at the time of the incident. The failure to provide adequate oxygen supply resulted in the resident running out of oxygen and requiring emergency medical intervention.