Failure to Provide Physician-Ordered Oxygen During Resident Transfer
Penalty
Summary
A resident with a diagnosis of chronic respiratory failure with hypoxia had a physician's order for three liters of continuous oxygen via nasal cannula. Upon discharge, the resident was transferred to another nursing facility approximately 100 miles away using a public transportation service. There was no documentation to show that arrangements were made to provide the resident with continuous oxygen during transport, as ordered by the physician. The registered nurse responsible for the discharge was unsure if the resident had portable oxygen at the time of discharge and could not confirm if a hand-off report was given to the receiving facility. The director of nursing and assistant director of nursing stated it was the discharging nurse's responsibility to ensure portable oxygen was available for the resident during transport, and if the receiving facility did not provide it, the sending facility should have supplied it. The facility's policy required staff to ensure portable oxygen tanks had adequate volume, but there was no evidence this was followed.