Failure to Ensure Safe and Accurate Oxygen Therapy Delivery
Penalty
Summary
The facility failed to ensure safe and accurate delivery of oxygen therapy for a resident with significant cardiac and respiratory diagnoses, including coronary artery disease, heart failure, and acute respiratory failure with hypoxia. The resident's care plan and physician's orders specified continuous oxygen therapy at 2-3 liters via nasal cannula to maintain oxygen saturation above 88%. However, multiple observations revealed that the oxygen concentrator was set below the ordered range, at 1 1/2 and 1 3/4 liters, and at one point, the resident was found without oxygen, with both the concentrator and portable tank turned off and the tubing stored away. The resident had to request staff assistance to have her oxygen reapplied. Staff interviews indicated a lack of clarity and consistency in following the oxygen therapy orders. A CNA reported that she only turns the oxygen on or off and does not adjust the flow rate, while an RN initially believed the oxygen was set correctly but, upon closer inspection, found it was below the ordered rate and adjusted it. These actions and inactions resulted in the resident not receiving oxygen therapy as ordered, constituting a failure to provide safe and appropriate respiratory care.