Failure to Ensure Accurate Oxygen Administration for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents who required oxygen therapy, as evidenced by observations, interviews, and record reviews. For each of these residents, the oxygen concentrator settings did not match the physician's orders or the care plan interventions. Specifically, one resident's oxygen was set at 4.5 liters per minute instead of the ordered 2.5-3 liters, another resident's oxygen was set at 2 liters per minute instead of the ordered 3 liters, and a third resident's oxygen was set at 2.5 liters per minute instead of the ordered 3 liters. These discrepancies were observed during routine checks and confirmed through interviews with staff and review of medical records. Interviews with Certified Nursing Assistants (CNAs) revealed that they were not responsible for checking or adjusting oxygen concentrator settings and were unaware of the correct settings for the residents. The responsibility for verifying the oxygen settings was assigned to the nursing staff, specifically Licensed Vocational Nurses (LVNs), at the start of each shift. However, the LVN interviewed admitted to not checking the oxygen concentrator settings for the affected residents over the previous four days, resulting in the settings remaining incorrect for an extended period. Further interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that nurses on each shift were expected to verify that oxygen concentrator settings matched physician orders. The facility's policy required regular assessment and correct administration of oxygen therapy, but this was not followed, as evidenced by the failure to ensure the prescribed oxygen flow rates were maintained for the residents in question. The residents involved had significant respiratory diagnoses, including COPD, respiratory failure, and hypoxia, and were dependent on accurate oxygen administration as part of their care.