Failure to Provide Ordered Oxygen Therapy Results in Resident Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of pneumonia and cerebral vascular accident, who had a physician's order for oxygen at bedtime due to hypoxia, did not receive the ordered respiratory care. The resident required oxygen at 2 liters/minute via nasal cannula at bedtime, as documented in the medical record and care plan. On the evening in question, the LPN responsible for administering medications and treatments signed off in the Medication Administration Record that the oxygen was applied, but later admitted to forgetting to place the nasal cannula on the resident and to turn on the oxygen. The resident was found later that night by staff in respiratory distress, with an oxygen saturation of 54% on room air and without the nasal cannula in place. The oxygen tubing was observed to be attached to the wall regulator, but the oxygen was not turned on. Immediate interventions were initiated by nursing staff, including increasing oxygen flow, administering a breathing treatment, and applying a non-rebreather mask, but the resident's oxygen saturation remained low. The resident was subsequently transferred to the emergency department for evaluation and treatment of respiratory distress. Interviews with staff confirmed that the LPN had signed for the administration of oxygen without actually providing it, and that the omission was not discovered until the resident was found in distress. The facility's policy required verification and administration of oxygen as ordered, as well as monitoring for signs of hypoxia, but these steps were not followed. The incident was documented in the facility's incident report and confirmed through staff interviews and medical record review.