Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered continuous oxygen therapy to a resident with significant medical needs. The resident had diagnoses including pneumonia, anxiety, and hemiplegia/hemiparesis following a stroke, and her admission MDS documented intact cognition with receipt of oxygen. Her Care Area Assessment noted impaired physical functioning related to a past stroke with left-sided weakness and a need for staff assistance with all care. The resident’s care plan documented she was to be on oxygen related to ineffective gas exchange, with an order for two liters of oxygen continuously. Physician’s orders directed staff to monitor oxygen saturation and provide oxygen at two liters every day and night shift. During observation, the resident was seated in the dining room in a wheelchair with a portable oxygen tank attached to the back of the wheelchair and a bag containing nasal cannula tubing. The nasal cannula prongs were hanging freely and were not in use, and the resident was not receiving oxygen despite the continuous oxygen order. When a licensed nurse placed the nasal cannula on the resident and attempted to turn on the oxygen, the portable tank was found to be empty, and the nurse then returned the resident to her room to place her on oxygen via a concentrator. Subsequent interviews with a CMA and another licensed nurse confirmed their understanding that the resident required oxygen all the time, and an administrative nurse stated she expected nurses to follow the oxygen orders. The facility’s oxygen therapy policy stated that residents would use oxygen from a portable source when off the main concentrator, but this was not implemented for the resident at the time of observation.
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