Failure to Provide Ordered Oxygen Therapy After Personal Care
Penalty
Summary
A resident with diagnoses including dementia, fibromyalgia, hypertension, and muscle weakness, who was completely dependent on staff for personal care and had severely impaired cognition, was admitted with an order for routine oxygen therapy via nasal cannula at 2-4 liters per minute. During personal hygiene care, a Certified Nursing Assistant (CNA) removed the resident's oxygen tubing to prevent it from pulling while repositioning the resident and subsequently forgot to replace it. The resident was left without the ordered oxygen therapy following this care. Later, a Licensed Vocational Nurse (LVN) was informed that the resident's oxygen tubing was off. Upon assessment, the resident was not in visible distress or short of breath, but their oxygen saturation was found to be 77%, significantly below the normal range of 95%-100%. The LVN immediately reapplied the oxygen, resulting in the resident's oxygen saturation rising to 95%. The facility's policy required oxygen therapy to be administered via nasal cannula, but this was not followed during the incident.