Improper Use of Non-Rebreather Mask for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not using a non-rebreather mask according to professional standards for a resident with impaired respiratory status. The resident, who had diagnoses including type II diabetes, stage III kidney disease, and unspecified dementia, was ordered to receive oxygen at 5 liters per minute via non-rebreather mask after experiencing low oxygen saturation levels. Staff interviews revealed that the non-rebreather mask did not fit the resident properly due to multiple skin folds, requiring staff to hold the mask in place. Additionally, the mask was administered at a flow rate of 5 liters per minute, which is below the standard practice of 10 to 15 liters per minute as outlined by the National Institute of Health guidelines. Nursing staff involved were either unaware of the correct flow rate for non-rebreather masks or followed the provider's order without verifying the standard of care. The nurse practitioner who gave the order was not aware that the facility's oxygen concentrators could deliver up to 10 liters per minute and based the order on incorrect information about equipment capabilities. The facility did not have a policy specific to the use of non-rebreather masks, contributing to the improper administration of oxygen therapy for the resident.