Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with acute respiratory failure and hypercapnia, who was dependent on staff for all activities of daily living and required continuous oxygen therapy per physician order, was left without her oxygen concentrator for an extended period. The resident's care plan and physician orders specified continuous oxygen via nasal cannula at 2-4 L/min, and the facility's policy required oxygen to be administered according to provider orders and standards of practice. However, during a transfer from wheelchair to bed, the oxygen concentrator was left in a common area and not returned to the resident's room until after she was already in bed. Multiple staff interviews revealed a lack of clear communication and responsibility regarding the transfer and reapplication of the oxygen concentrator. The CNA responsible for the transfer stated that the resident was without oxygen for approximately 20 minutes, and neither the LPN nor the RN at the nurse's desk assisted or ensured the oxygen was reapplied promptly. The resident was observed lying in bed without oxygen, displaying a sad expression and being non-responsive to questions. Staff confirmed that the resident was supposed to have continuous oxygen and acknowledged the potential for hypoxia if oxygen was not provided as ordered. Documentation showed that after the lapse, the resident's oxygen was reapplied, and her vital signs and oxygen saturation were within normal limits. However, the incident demonstrated a failure to provide safe and appropriate respiratory care consistent with professional standards and physician orders. Staff interviews also indicated a lack of recent in-service training on oxygen care and protocol, contributing to the deficiency.