Failure to Ensure Proper Administration of Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), muscle wasting, dysphagia, hypertension, peripheral vascular disease, and gout, was observed receiving oxygen therapy that was not properly administered. The resident, who had a severely impaired cognitive status, was found lying in bed with the oxygen concentrator turned on and set to 2LPM, but the oxygen tubing was not connected to the concentrator, despite being properly placed on her face via nasal cannula. At the time of observation, the resident did not exhibit symptoms of respiratory distress, and oxygen saturation readings were taken by two staff members, showing levels of 93% and 96%. Interviews with nursing staff revealed that nurses were responsible for checking the oxygen equipment and saturation levels at least once per shift. Staff indicated that the resident tended to move around, which may have led to the tubing becoming disconnected. The care plan and physician's orders specified the need for oxygen therapy and monitoring for signs and symptoms of respiratory distress. The facility's policy, based on the Lippincott Manual of Nursing Practice, required proper administration and fit of oxygen delivery devices. The failure to ensure the oxygen tubing was connected as ordered constituted a lapse in following professional standards and the resident's care plan.