Failure to Administer Ordered Oxygen Flow Rate and Verify Respiratory Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards of practice and the resident’s person-centered care plan. A cognitively intact resident with diagnoses including respiratory failure (unspecified hypoxia/hypercapnia), obstructive sleep apnea, pulmonary embolism without acute cor pulmonale, and hypertension had a physician’s order, in place since 11/18/2024, for oxygen therapy at four liters per minute via nasal cannula every day, every shift. The resident’s care plan for risk of compromised respiratory status directed staff to monitor respiratory status, breath sounds, activity tolerance, vital signs, and to provide oxygen per physician order and consult Respiratory Therapy as needed. The facility’s oxygen administration policy required verification of the physician’s order and setting the oxygen flow as prescribed. On the date in question, the resident’s health care proxy reported that during a visit, the resident complained of trouble breathing. The proxy removed the nasal cannula and perceived that no air was coming out. They checked the oxygen concentrator, which they believed was set at three or four liters, and observed it was not working; when they attempted to increase the flow, the floating ball did not move. The proxy sought assistance from a nurse, who reportedly stated they could not help and that an order was placed for a Respiratory Therapy consult. According to the proxy, no staff entered the room before they left temporarily, and during that time the resident’s granddaughter noticed a portable oxygen tank in the room, asked staff for help and was told they could not assist, and then independently connected the nasal cannula to the portable tank without knowing the oxygen flow setting. Later that day, a Respiratory Therapist assessed the resident after being called by an LPN for reported shortness of breath. The Respiratory Therapist found the resident in their room during dinner, eating pizza and in no apparent distress, with even, unlabored respirations and clear bilateral lung sounds. At that time, the resident was on a portable oxygen tank set at three liters per minute, with an oxygen saturation of 92%. The Respiratory Therapist switched the resident from the portable tank to the oxygen concentrator, maintaining the flow at three liters per minute, and documented the assessment and oxygen saturation. The Respiratory Therapist later stated they were not aware the resident was ordered four liters of oxygen and did not verify the current physician order, relying instead on a recollection that the resident had previously been on three liters during their stay. Subsequent review by the DON confirmed that the physician’s order in effect required four liters of oxygen.
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