Failure to Provide Continuous Oxygen Therapy During Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of chronic respiratory conditions, including COPD, congestive heart failure, and acute and chronic respiratory failure with hypoxia, did not receive continuous oxygen therapy as ordered by his physician. The resident required oxygen at 3LPM via nasal cannula and had documented needs for continuous oxygen to maintain adequate oxygen saturation. During a transfer from wheelchair to bed using a Hoyer lift, two CNAs removed the resident's nasal cannula, leaving him without supplemental oxygen for several minutes. The CNAs struggled with the transfer, and during this time, the resident repeatedly requested oxygen and showed signs of respiratory distress, including turning blue and gasping for air. The CNAs did not immediately restore the oxygen, and only after the transfer was completed was the nasal cannula reattached and oxygen flow resumed. Video evidence and interviews confirmed that the resident was without oxygen for an extended period during the transfer, despite his repeated verbal requests and visible signs of distress. The CNAs involved stated they removed the oxygen because they believed the tubing would not reach or might get tangled during the transfer, and both acknowledged they were not trained or authorized to remove or adjust oxygen devices. Other CNAs and nursing staff interviewed confirmed that only licensed nurses should handle oxygen administration and that it was not standard practice to remove oxygen during transfers for residents with respiratory needs. The facility's policies also indicated that oxygen delivery devices should be managed according to standard practice guidelines and that CNAs should notify a licensed nurse if oxygen needed to be removed. Following the transfer, the resident became unresponsive and required emergency intervention. Nursing staff assessed the resident, found him to be breathing with a faint pulse, and provided high-flow oxygen while awaiting emergency services. Despite these interventions, the resident was later pronounced dead at the hospital. The incident was identified as an Immediate Jeopardy situation due to the failure to provide care consistent with professional standards for respiratory therapy, specifically the failure to ensure continuous oxygen therapy as ordered.