Failure to Ensure Continuous Oxygen Supply for Resident on Oxygen Therapy
Penalty
Summary
Facility staff failed to ensure continuous oxygen therapy for a resident with COPD and chronic respiratory failure with hypoxia who had physician orders and care plan directives for continuous oxygen at 2–3 L/min via nasal cannula. The resident’s care plan, last revised on 10/29/25, specified that the resident was on oxygen therapy related to COPD, required continuous oxygen at 2–3 L/min, and for ambulatory residents, staff were to provide extension tubing or a portable oxygen apparatus. A physician’s order dated 12/11/25 directed oxygen supplementation at 2–3 L/min via nasal cannula every shift for COPD. A quarterly MDS assessment documented that the resident was cognitively intact with a BIMS score of 15, experienced shortness of breath with exertion, at rest, and when lying flat, and used oxygen therapy while in the facility. On 01/30/26 at 3:47 PM, the resident was observed alone in the 2-north stairwell, going down the stairs and noticeably short of breath, with oxygen via nasal cannula at 3 L/min and carrying a portable E-tank in a wheeled caddy. Upon inspection, the oxygen tank’s indicator was in the red area marked “0 refill,” indicating the tank was empty, meaning the resident was not receiving the ordered continuous oxygen. During a face-to-face interview shortly thereafter, the 2-south Unit Manager acknowledged that the resident’s oxygen tank was empty when the resident was observed short of breath and alone in the stairwell and stated that the assigned nurse was supposed to check and ensure that residents’ oxygen tanks were not empty when they left the unit. These observations and statements showed that staff did not ensure the resident’s continuous oxygen needs were met.
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