Failure to Ensure Proper Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that oxygen therapy was delivered as prescribed for a resident with a primary diagnosis of acute respiratory failure. Observations on two separate occasions revealed that the resident's nasal cannula was not properly positioned in the nostrils while oxygen was running at 2 liters per minute, as ordered by the physician. On one occasion, the nasal cannula was not in the resident's nostrils, and on another, it was observed in the resident's mouth. In both instances, staff were alerted by the surveyor to correct the placement of the oxygen tubing. Medical record review confirmed that the resident was admitted with acute respiratory failure and had physician orders for continuous oxygen via nasal cannula. The resident's care plan included interventions to administer oxygen as ordered and monitor for signs of respiratory distress. Staff interviews indicated that routine checks and vital sign monitoring were performed, but the improper placement of the nasal cannula was not identified by staff prior to surveyor intervention. The facility's policy required provision of respiratory therapy services as ordered by a physician.