Failure to Provide Safe and Consistent Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of non-ST elevation myocardial infarction and chronic obstructive pulmonary disease (COPD) was not provided with safe and appropriate respiratory care as required by professional standards. The resident had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed. On two separate occasions, surveyor observations revealed that the resident's portable oxygen cylinder was empty, and there was no evidence in the medication and treatment administration records that the resident's oxygen supply was being monitored to ensure continuous delivery as ordered. During these times, the resident's oxygen saturation levels were found to be critically low, registering at 78% and later fluctuating between 85% to 86%, both well below the normal range. Staff interviews indicated a lack of awareness regarding the duration of oxygen cylinder supply and a failure to utilize available oxygen concentrators in the facility. The resident had been using portable oxygen cylinders exclusively, despite the availability of functional oxygen concentrators, and staff did not monitor the oxygen supply frequently enough to prevent depletion. The Director of Nursing Services confirmed that the resident should have been using an oxygen concentrator in the room and a portable cylinder only when out of the room, and that staff were expected to monitor the resident more closely when using portable oxygen. These failures resulted in the resident experiencing periods of hypoxia due to an empty oxygen supply.