Failure to Maintain Proper Head of Bed Elevation During Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a history of respiratory failure, COPD, and dementia, who was dependent on staff for all activities of daily living and receiving oxygen therapy, was found with the head of bed positioned almost flat. The resident's medical orders included oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During observation, the resident was noted to be on oxygen with the bed nearly flat, contrary to the facility's policy requiring the head of bed to be elevated to at least 30 degrees when oxygen is applied. Staff interviews confirmed that the resident had been left in this position by a CNA, and a nurse acknowledged the head of bed was only at 15-20 degrees, which was not appropriate for a resident with shortness of breath. The facility's policy and procedure for oxygen therapy specifically stated that the head of bed should be elevated 30 degrees or higher for residents receiving oxygen. The failure to maintain the required bed elevation was directly observed and confirmed by staff, constituting a failure to follow established protocols for respiratory care.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: Resident 34 head of bed was immediately raised to 30 degrees by CN on 6/12/2025. DON and DSD rounded and found two other residents on continuous low dose oxygen with head of bed at 30 degrees or greater without discomfort. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON rounded and found no other residents were affected by deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: All licensed nurses in-serviced on 06/14/25 and 06/15/25 regarding head of bed to be greater than 30 degrees while on oxygen for comfort. Licensed nurses' daily check list and duties as soon as you step in, to include number 4: head of bed greater than 30-45 degrees. DON added to batch order set on electronic health template details to include "While on oxygen, keep head of bed at least 30 degrees or greater." Facility plan to monitor corrective action(s) and sustain compliance: Starting 7/01/25, DON or designee will review performance and report to the administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.