Failure to Ensure Proper Functioning of Portable Oxygen Tank
Penalty
Summary
The facility failed to ensure that a portable oxygen tank was functioning properly for a resident who required oxygen therapy. Observation revealed that the resident, who had a history of acute respiratory failure, pneumonia, heart failure, and other significant medical conditions, was short of breath while speaking. The resident's nasal cannula was attached to a portable oxygen tank, but the tank's dial was in the red area, indicating it was either empty or turned off. At this time, the resident's oxygen saturation was measured at 85%, which is below the physician-ordered threshold of 92%. A Licensed Practical Nurse (LPN) checked the oxygen tank, pressed a button, and the gauge moved, after which the resident's oxygen saturation increased to 89%. The LPN confirmed that the oxygen tank was not working when the resident was attempting to use it to maintain adequate oxygen saturation. Review of the facility's policy on oxygen administration indicated that guidelines were in place for safe oxygen use, but these were not followed in this instance, resulting in the resident not receiving appropriate respiratory care.