Failure to Ensure Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide ordered continuous oxygen therapy to a resident with multiple respiratory-related diagnoses. The resident had COPD, chronic respiratory failure with hypoxia, and a recent hospitalization for pneumonia, and the physician’s order and care plan required continuous oxygen at 2 L/min via nasal cannula. On observation, the resident was seated in a wheelchair with a nasal cannula connected to a portable oxygen tank, and an oxygen concentrator was also present in the room. When the resident’s POA questioned whether oxygen was infusing, staff checked the portable tank and found the gauge in the red zone, and the RN confirmed the tank was empty despite being set at 2 L/min. The resident reported that an aide had gotten her out of bed to the wheelchair but could not identify who or when, and the RN stated that whoever got the resident up had switched her from the concentrator to the portable tank. Subsequent interviews showed uncertainty among staff about who transferred the resident and who switched the oxygen source. The PTA reported therapy had not gotten the resident up that morning, and the DON stated that interviews with CNAs indicated none of them had transferred the resident and that the resident might have gotten herself up, as her daughter had previously commented that she was getting stronger and able to get out of bed on her own. CNAs and the DON stated that only nurses are responsible for disconnecting oxygen from the floor concentrator and connecting it to a portable tank, and that CNAs only assist with transfers and may adjust or reapply the nasal cannula. Facility policy specified that oxygen via compressed gas must be provided per physician orders by an RN or LPN, with CNAs/rehab aides limited to adjusting or reapplying the cannula or mask. Despite these orders and policies, the resident was found on an empty portable oxygen tank while ordered to be on continuous oxygen.
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