Failure to Ensure Physician-Ordered Oxygen Delivery for Resident with Tracheotomy
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for a resident with a tracheotomy and multiple respiratory diagnoses, including acute on chronic hypoxic respiratory failure, COPD, and heart failure. The resident was admitted following a hospital stay for pneumonia and COPD exacerbation, and was cognitively intact, managing her own tracheotomy care prior to admission. The resident's Minimum Data Set (MDS) assessment indicated a need for oxygen therapy, but the baseline care plan did not address the use of an oxygen concentrator. Observations revealed inconsistencies in the oxygen flow rate delivered to the resident. On one occasion, the oxygen concentrator was set to deliver 6 liters per minute, while on another, it was set to 10 liters per minute. An LPN acknowledged the need to review the physician's order and adjust the concentrator accordingly, indicating that the oxygen delivery was not consistently aligned with the physician's prescribed amount. Facility leadership did not provide comments or express concerns when interviewed about these findings.