Failure to Ensure Timely Administration of Supplemental Oxygen
Penalty
Summary
Facility staff failed to ensure that supplemental oxygen was administered in accordance with physician orders and individual care plans for two residents. For one resident with diagnoses including Parkinson's disease, coronary artery disease, and a right femur neck fracture, physician orders required oxygen at 2-3 liters per minute as needed to maintain oxygen saturation above 90%. Observations revealed that this resident was seated in a wheelchair with a nasal cannula attached to an oxygen tank that was empty or nearly empty, as indicated by the tank gauge in the red range, during both morning and afternoon checks. Staff interviews indicated that responsibility for changing oxygen tanks was shared among nurses and aides, but there was reliance on aides to notify nurses when tanks were low or empty. Another resident, with diagnoses including rheumatoid arthritis and requiring oxygen therapy for hypoxia, was observed in the dining room with an empty oxygen tank and not wearing her nasal cannula. Later, her tank was exchanged and she was observed wearing the nasal cannula with a half-full tank. The care plan for this resident included monitoring for respiratory distress and ensuring proper oxygen therapy. These observations demonstrate that staff did not promptly intervene to ensure oxygen was administered as ordered, resulting in residents not receiving prescribed oxygen therapy.