Failure to Provide Adequate Oxygen Therapy During Resident Transport
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), chronic hypoxic respiratory failure, and a history of lung cancer was transported to an orthopedic appointment with only one portable oxygen E-cylinder, despite a physician order for continuous oxygen at 6-8 liters per minute (LPM). During the appointment, the resident's oxygen supply was depleted, and no backup oxygen tank was available on the transport vehicle. The resident's oxygen saturation dropped to around 70% while waiting for supplemental oxygen, and staff at the orthopedic clinic had to assist until a replacement tank was retrieved from the facility. Interviews with facility staff revealed a lack of clarity and adherence to protocols regarding oxygen therapy during transport. The certified nursing assistant (CNA) responsible for preparing the resident believed that backup tanks were not permitted per facility policy, while the registered nurse (RN) was unaware of the need for a backup tank and underestimated the rate at which the oxygen would be consumed at the prescribed flow rate. The transport driver confirmed that the vehicle was not equipped with additional oxygen tanks and had to return to the facility to obtain one. Review of facility policies and vendor documentation indicated that an E-tank at a 6 LPM flow rate would last approximately 75 minutes, and that a nasal cannula should not be used for flow rates above 6 LPM. The resident was transported with a nasal cannula set at 8 LPM, contrary to policy, which requires a simple face mask for higher flow rates. The facility's failure to provide adequate oxygen supply and appropriate delivery equipment during transport resulted in the resident experiencing severe hypoxemia and distress.