Resident Transported with Empty Oxygen Tank Due to Equipment and Process Failures
Penalty
Summary
A deficiency occurred when a resident who required continuous supplemental oxygen due to chronic respiratory failure, congestive heart failure, and a history of pneumonia was transported to a doctor's appointment with an empty oxygen tank. The resident's care plan specified the need for continuous oxygen via nasal cannula at a prescribed flow rate. On the day of the appointment, the responsible party noticed the oxygen tank was empty, and the resident exhibited symptoms of shortness of breath and gasping for air. The resident was subsequently transported to the hospital from the doctor's office and admitted to the emergency room. Interviews with facility staff revealed that the charge nurse was responsible for ensuring residents leaving the facility had a full oxygen tank. The nurse assigned to the resident reported checking and replacing the oxygen tank with a full one prior to departure and again just before leaving, noting it was full. However, the resident arrived at the appointment with an empty tank, and the transportation staff had to return to the facility to retrieve a replacement. The resident's symptoms prompted the doctor's office staff to call emergency medical services. Further investigation indicated that the facility's oxygen refilling station had been intermittently malfunctioning, with reports of tanks appearing full when they were not, and a red warning light being observed. Some staff were aware of these issues, while others were not. The malfunctioning equipment contributed to the failure to provide the resident with an adequate supply of oxygen during transport, as required by professional standards of practice and the resident's care plan.