Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia, who had severe cognitive impairment and an activated Power of Attorney, was admitted with a physician's order for continuous oxygen at no more than 3 liters per minute (LPM) to maintain oxygen saturation at 90% or above. During observation, the resident was seen in a wheelchair with a nasal cannula connected to a portable oxygen tank that was not turned on, and the tank was set at 0. Upon verification by an LPN, it was confirmed that the oxygen should have been set at 2 LPM continuously, and that CNAs were responsible for turning on the oxygen tank unless an adjustment was needed. The resident's oxygen saturation was measured at 69% before the oxygen was turned on and increased to 97% after the oxygen was set to 2 LPM. Further review revealed that the facility did not have an oxygen use policy in place, as confirmed by the Director of Nursing. The resident's medical record included orders for continuous oxygen and regular checks and changes of oxygen tubing, but these were not followed at the time of the surveyor's observation. The failure to ensure the resident's oxygen was administered as ordered constituted a deficiency in providing necessary respiratory care and services.