Failure to Ensure Adequate Oxygen During Resident Transport
Penalty
Summary
A deficiency occurred when a resident who required continuous oxygen therapy was not provided with adequate oxygen during a community appointment. The resident, who had a history of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, and other comorbidities, was transported to a dental appointment with a full portable oxygen tank. The appointment lasted significantly longer than expected, resulting in the resident being away from the facility for approximately five hours. During the return trip, the resident's portable oxygen tank ran out, and he began experiencing shortness of breath. Staff accompanying the resident, including a CNA, noticed the resident's respiratory distress and checked the oxygen tank, finding it nearly empty. The CNA contacted the ADON, who instructed them to pull over and call 911. Emergency medical services arrived and found the resident with an SpO2 of 50%. The resident was transported to the hospital, where he was diagnosed with acute hypoxia and acute on chronic respiratory failure with hypoxia and hypercapnia. The resident reported feeling unable to breathe and nearly blacking out before EMS arrived. Prior to the incident, the facility's procedures for oxygen administration did not address the specific needs of residents on continuous oxygen therapy during transportation outside the facility. Staff interviews confirmed that while checks were made to ensure tanks were full before departure, there was no protocol for providing an extra tank for longer appointments. The deficiency was identified as past non-compliance, with the immediate jeopardy period beginning and ending within a two-day span.