Failure to Administer Prescribed Oxygen Rate and Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents. For one resident with a history of congestive heart failure and chronic obstructive pulmonary disease, physician orders specified oxygen at 2 liters via nasal cannula as needed for shortness of breath. However, multiple observations over several days revealed that the oxygen concentrator was set at 1.5 liters instead of the prescribed 2 liters. Nursing staff confirmed the discrepancy and were unable to explain why the ordered rate was not being administered, despite checking oxygen rates during medication passes. The Director of Nursing stated that her expectation was for oxygen to be delivered at the ordered rate. For another resident with severe cognitive impairment and a physician order for continuous supplemental oxygen at 2 liters per minute, two unsecured oxygen E cylinders were found stored upright in the resident's room. Facility policy and staff interviews indicated that oxygen cylinders should be stored in designated storage rooms with upright holders or in a transport caddy, not in resident rooms unsecured. The Director of Nursing confirmed that the cylinders should not have been left in the resident's room unsecured.