Failure to Timely Administer Oxygen Therapy for Resident with Shortness of Breath
Penalty
Summary
A deficiency occurred when a resident with a history of hypertensive heart disease, heart failure, shortness of breath (SOB), and pulmonary embolism did not receive oxygen therapy as ordered by the physician. The resident had a physician's order for PRN oxygen at 2 liters per minute for SOB and wheezing, with the option to titrate up to 3-4 liters. On the morning in question, the resident began experiencing SOB and reported feeling unwell to staff at approximately 8 AM. Despite these complaints and a documented oxygen saturation as low as 88% on room air, oxygen was not administered until approximately 4:30 PM, resulting in an 8.5-hour delay. Throughout the day, multiple staff members, including a CNA, LVN, and RN, were made aware of the resident's symptoms. The resident continued to complain of SOB and headache, and family members were also informed by the resident of her distress and lack of oxygen administration. Vital signs taken during this period showed fluctuating oxygen saturation levels, with a notable drop to 91% and 88% at different times. Despite these findings and the resident's ongoing complaints, staff did not initiate oxygen therapy as per the physician's order, and instead, the resident was referred for a psychiatric consult for possible anxiety. It was not until the resident's condition worsened, with labored breathing, bilateral wheezing, and use of accessory muscles, that oxygen was finally administered using a non-rebreather mask, and emergency services were called. The resident was subsequently transferred to a general acute care hospital for respiratory distress, where further evaluation revealed edema and infection. Interviews with staff and the resident confirmed that oxygen was not provided in a timely manner, despite clear indications and physician orders.