Failure to Ensure Proper Oxygen Orders, Settings, and Equipment Handling
Penalty
Summary
The deficiency involves failures in providing safe and appropriate respiratory care, including incorrect oxygen settings, unlabeled and improperly stored respiratory equipment, and use of oxygen without a physician order. One resident with COPD, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and pulmonary hypertension had care plan interventions directing staff to administer oxygen as ordered. The physician order allowed oxygen via nasal cannula at 1–5 L/min continuous. During observation, this resident was on 3 L/min via nasal cannula with the wall flow meter set at 3 L/min, and the nebulizer mask was found lying on a bedside table, unlabeled and not stored in a bag. Another resident with primary pulmonary hypertension, acute and chronic respiratory failure with hypoxia, and chronic systolic congestive heart failure had a care plan indicating PRN oxygen therapy related to chronic respiratory failure and interventions to administer oxygen per MD orders. This resident was observed in bed with a nasal cannula in place while the wall oxygen flow meter was turned off. An oxygen tank with a nasal cannula attached was on the wheelchair, undated and without a storage bag. The resident reported using oxygen sometimes as needed and stated the prescribed amount was 2 L, but when the surveyor checked, the flow meter was set at zero and the resident reported not feeling any oxygen until the nurse turned the flow meter to 2 L. A third resident with diagnoses including pleural effusion, chronic pulmonary edema, pneumonia, acute metabolic acidosis, and acute and chronic respiratory failure with hypoxia was admitted without any physician order for oxygen in the electronic medical record and without a care plan addressing oxygen use. Despite this, the resident’s oxygen concentrator was observed running at 1 L/min via nasal cannula, and the resident stated they had been using oxygen since admission. The acting DON/nurse consultant stated that there should be a physician order and care plan for oxygen, that oxygen should only be given without an order in an emergency, and that nasal cannulas and nebulizer masks should be stored in clean bags and dated when changed, consistent with facility policies on oxygen therapy and equipment storage and change schedules.
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