Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
A resident with chronic respiratory failure, COPD, and hypoxia, who is dependent on supplemental oxygen, did not receive oxygen therapy as ordered by the physician. The physician's order specified oxygen at 2 liters per nasal cannula to maintain oxygen saturation at or above 95%. However, observations revealed that the resident's oxygen concentrator was frequently set at 3.5 liters, exceeding the prescribed amount, and the oxygen tubing was not one continuous piece as required by an intervention following a previous incident. Instead, two oxygen tubes were connected together, contrary to the facility's stated intervention to prevent disconnection. On one occasion, the resident was found with disconnected oxygen tubing, resulting in an oxygen saturation of 80%. The ambulance crew discovered the disconnection at the connector, and the facility determined that the likely cause was the resident moving in bed and pulling the tubing apart. Despite this, subsequent observations showed that the resident continued to receive oxygen through two connected tubes, and the care plan was not updated to reflect the intervention of using a single continuous tube. Staff members, including a CNA and LPN, were observed providing care without adjusting the oxygen flow to the ordered rate, and the LPN was unaware of the correct physician order until informed by the surveyor. Additionally, the facility's care plans for oxygen therapy and respiratory conditions were not revised to include the intervention of using a single continuous tube, as discussed by the interdisciplinary team after the hypoxic incident. Multiple staff members failed to ensure the resident received oxygen at the prescribed rate and with the correct tubing setup, as evidenced by repeated surveyor observations and staff interviews.