Failure to Ensure Proper Oxygen Administration for Resident Requiring Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and coronary artery disease, who required continuous oxygen therapy, was observed wearing an oxygen nasal cannula that was not connected to the oxygen machine. The oxygen machine was on and set to deliver two liters per minute, but the tubing was disconnected at the machine end, resulting in the resident not receiving the prescribed oxygen. The resident, who had moderate cognitive impairment, stated he wore the oxygen all the time and believed it was running, though he did not feel short of breath at the time of observation. The charge nurse confirmed that the oxygen tubing was not connected to the machine and acknowledged the risks associated with improper oxygen setup. The resident's care plan included interventions for oxygen therapy, but there was no documented focus area specifically for COPD. Additionally, when the facility's respiratory care policy was requested, it was not provided before the survey exit.