Failure to Ensure Supplemental Oxygen Provided as Ordered
Penalty
Summary
Staff failed to provide safe and appropriate respiratory care by not ensuring that a resident on continuous oxygen therapy received supplemental oxygen as ordered. The resident, who had diagnoses including atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, and a cardiac pacemaker, was observed on two separate occasions in the dining room with an oxygen tank that was empty, as indicated by the gauge needle in the red zone. The nasal cannula was attached to the resident but the tank was not supplying oxygen. The resident required minimal assistance with activities of daily living and had intact cognitive ability. Interviews with staff revealed that the LPN who assisted the resident to the dining room did not check the oxygen tank, and staff relied on CNAs to notify them if a tank was empty. The DON acknowledged that at the prescribed flow rate, tanks would empty quickly and staff should have monitored them more closely. The facility did not have a policy for supplemental oxygen use and did not provide documentation of staff education on standards of care for oxygen therapy.