Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice and facility policy for a resident requiring oxygen therapy. The resident, who had multiple diagnoses including acute respiratory failure with hypoxia, Parkinson's disease, heart failure, and cognitive deficits, required continuous oxygen via nasal cannula at two to three liters per minute. During an episode of shortness of breath and low oxygen saturation (87-89%), a nurse applied a simple mask but did not adjust the oxygen flow rate above 3 liters per minute, contrary to facility policy which requires a minimum of 5 liters per minute for a simple mask. When emergency medical services arrived, the oxygen flow was found to be only 1 liter per minute via simple mask, and the squad had to increase it to 8 liters per minute, resulting in improved oxygen saturation and responsiveness before hospital transfer. Interviews with multiple LPNs revealed a lack of knowledge regarding appropriate oxygen flow rates for different delivery systems, particularly the simple mask. The contracted respiratory therapist confirmed he had not provided education to staff on oxygen flow rates, and the Director of Nursing acknowledged that staff education on this topic had not been conducted. Observation of the facility's respiratory supply room showed the availability of various oxygen delivery devices, but staff were not adequately trained in their use, leading to improper administration of oxygen therapy for the resident.