Failure to Ensure Proper Placement of Oxygen Nasal Cannula
Penalty
Summary
A deficiency occurred when a resident with diagnoses of congestive heart failure, pleural effusion, and respiratory failure, who was dependent on staff for all activities of daily living, was observed with her oxygen nasal cannula improperly placed inside her mouth while she was sleeping. The resident's care plan required continuous oxygen via nasal cannula, and the physician's order specified oxygen at 2 liters per minute for shortness of breath, with the option to increase up to 5 liters if necessary. During the observation, a CNA acknowledged the importance of proper nasal cannula placement and stated that if it was found out of place, the charge nurse should be notified to address the issue. Further interviews with nursing staff and the DON confirmed that professional standards of practice require checking the placement of the nasal cannula during routine room checks and that the facility's policy specifies the nasal cannula should be placed approximately one-half inch into the resident's nose. The staff confirmed that the doctor's order for oxygen must be followed as written. The failure to ensure the nasal cannula was properly placed in the resident's nose resulted in the resident not receiving oxygen as prescribed.