Failure to Provide Appropriate Oxygen Therapy for Resident with Low Oxygen Saturation
Penalty
Summary
Facility staff failed to provide respiratory care services consistent with professional standards of practice for a resident with a history of respiratory failure, prostate cancer, and dementia. The resident, who had severely impaired cognition and required significant assistance with daily activities, was admitted with physician orders to receive oxygen at 2 to 5 liters per minute (LPM) via nasal cannula, with instructions to titrate oxygen if saturation fell below 90%. On the morning in question, the resident was documented to have an oxygen saturation level of 80% while receiving oxygen via nasal cannula. Despite the low oxygen saturation, there was no documented evidence that staff increased the oxygen flow rate or administered high concentration oxygen using a non-rebreather mask prior to the arrival of paramedics. Interviews with the DON and a registered nurse confirmed that the resident continued to receive oxygen at 5 LPM via nasal cannula and was not switched to a non-rebreather mask. The facility's own policy required staff to adjust oxygen delivery devices and flow rates as needed and to document all assessment data and interventions, but this was not done in this case. When paramedics arrived, they found the resident with an oxygen saturation of 83% on 4 LPM via nasal cannula, a heart rate of 122, and a respiratory rate of 41. Paramedics questioned facility staff about the lack of appropriate oxygen therapy, but no explanation was provided. The paramedics then administered oxygen at 15 LPM via non-rebreather mask and provided additional care before transferring the resident to the hospital.