Failure to Provide Ordered Continuous Oxygen During Resident Transport
Penalty
Summary
A resident with a history of coronary artery disease and pneumonia was admitted to the facility with a physician's order for continuous oxygen at 2 liters per minute. The resident's care plan and Medication Administration Record (MAR) reflected this order, and staff were expected to ensure the resident received continuous oxygen therapy. On the day in question, the resident became lethargic, confused, and was not eating or drinking, prompting the Nurse Practitioner to order transport to the emergency room (ER) for further evaluation. Multiple staff members, including nurses and nurse aides, were involved in preparing the resident for transport to the ER. However, none could definitively recall whether the resident was wearing or provided with oxygen during the transfer. The transportation aide, who drove the resident to the ER in a facility van, also could not confirm if oxygen was administered during the trip. Upon arrival at the ER, the resident was found to be unresponsive with an oxygen saturation of 81% on room air, and it was noted by ER staff that the resident was not receiving oxygen despite a standing order for continuous therapy. After oxygen was applied in the ER, the resident's oxygen saturation improved to 94%. The ER physician confirmed that the resident arrived without oxygen, despite the documented order for continuous use. Interviews with facility staff, including the Director of Nursing, indicated an expectation that residents with such orders would be transported with oxygen, but this was not implemented in this case. The failure to provide continuous oxygen as ordered during transport constituted a deficiency in the facility's provision of safe and appropriate respiratory care.