Failure to Restart Oxygen After Tubing Change
Penalty
Summary
The facility failed to ensure that a resident dependent on supplemental oxygen received ordered oxygen therapy following a tubing change. The resident had multiple respiratory-related diagnoses, including COPD, morbid obesity, alveolar hypoventilation, a history of pulmonary embolism, and was ordered to receive 2–4 L oxygen via nasal cannula to maintain oxygen saturation above 90%, with tubing to be changed and dated every 7 days and as needed. The facility’s Standard Respiratory Protocol directed RNs to apply oxygen as ordered for individuals with impaired or potential impairment of gas exchange. On the night of 1/9/26, an RN changed the resident’s oxygen tubing but did not turn the oxygen back on afterward. Following the tubing change, the resident reported turning on the call light and calling the nurses’ station, but stated that no one answered. The resident, who was cognitively intact and their own decision maker, stated that a CNA discovered in the morning that the oxygen was off and then turned it back on. The CNA confirmed that, upon checking the resident that morning, the oxygen was not on and that the resident reported the RN had changed the tubing without restarting the oxygen, resulting in the resident being without oxygen for most of the night, approximately six hours. The Regional Nurse Consultant stated they were not aware that the resident had gone without oxygen.
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