Failure to Follow Oxygen and PAP Device Protocols and Address Low SpO2
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services consistent with professional standards of practice and its own CPAP/BiPAP Support Level III policy. The policy directed staff to connect supplemental oxygen only after the CPAP machine was turned on and to disconnect oxygen before turning the CPAP machine off, and to adjust the flow rate as prescribed. For one resident with a history including transient cerebral ischemic attack and chronic kidney disease, the medical record showed an SpO2 of 82% on room air on a documented date, with no nursing interventions related to this low oxygen saturation recorded in the nursing notes. The MDS RN later stated that this low SpO2 level should have been addressed by nursing staff but was not. For two other residents with multiple diagnoses, including diabetes, hallucinations, and a lower right leg fracture, surveyors observed oxygen being bled into their PAP devices while the PAP devices were not turned on or in use. One resident’s oxygen was observed at 3 LPM and the other’s at 2 LPM under these conditions. In both cases, the MDS RN stated that the oxygen should have been turned off before the PAP device was turned off when the residents were done using the PAP devices, but this was not done. These observations and record reviews showed that staff did not follow the facility’s policy and professional standards for safe use of oxygen with PAP devices and did not document appropriate nursing response to a significantly low SpO2 reading.
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