Failure to Ensure Oxygen Delivery Device Was Connected for Resident Requiring Continuous Oxygen
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards for a resident with a history of respiratory failure with hypoxia, congestive heart failure, and dementia. The resident was dependent on staff for all activities of daily living and had a physician's order for continuous oxygen therapy via nasal cannula, with instructions to titrate as needed. During observation, the resident was found in bed with the nasal cannula placed near the nostrils, but the tubing was disconnected from the oxygen concentrator and hanging from the bed. Licensed staff confirmed that the oxygen tubing should always be connected to the oxygen source and that it is the responsibility of both licensed staff and certified nurse assistants to ensure the connection is intact. Interviews with the LVN and DON confirmed that staff are expected to routinely monitor oxygen tubing to ensure it is connected and functioning properly. Review of the facility's policy on oxygen administration indicated that staff should check tubing connections and ensure proper oxygen delivery. The failure to connect the nasal cannula to the oxygen concentrator was directly observed and acknowledged by staff, and the facility's own policy supports the need for such monitoring and connection.