Failure to Administer and Monitor Ordered Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure oxygen therapy and maintenance were administered and monitored as ordered for one resident who required respiratory care. The resident had multiple diagnoses, including chronic diastolic congestive heart failure, chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy, and a urinary tract infection. On the day of the incident, nursing documentation showed the resident was hallucinating, with vital signs including an oxygen saturation of 90%, and the resident was placed on 2 L O2 via nasal cannula per a new clinician order to titrate oxygen to keep saturation above 93% and to monitor oxygen saturation every shift for levels at or below 90%. A change in condition note documented altered mental status and hallucinations, and that the primary care provider ordered a urinalysis and oxygen therapy. Later that afternoon, a nursing note documented that the resident’s daughter called 911 due to concern about the resident’s hallucinations. The note stated the resident repeatedly removed the oxygen despite redirection, that oxygen was replaced but the resident continued to remove it, and that education and reassurance were provided without sustained compliance. The nurse documented that, per family request, the resident was sent to the hospital via EMS in stable condition, and that at the time of EMS departure the resident was sitting upright, drinking a beverage, and not wearing oxygen. However, there were no documented oxygen saturation readings under 90% in the medical record and no additional respiratory assessments were identified, despite the order to titrate oxygen and maintain saturation above 93%. The EMS report for the same day documented that upon arrival the resident was in bed, confused, lethargic, and experiencing visual hallucinations, with an SpO2 of 86% on room air. EMS initiated 15 L/min O2 via non-rebreather mask, which stabilized the oxygen saturation. The EMS report also noted that staff stated EMS was unable to speak to the resident’s nurse because she was not present, and that history was primarily obtained from the daughter, who reported being notified earlier that the resident had low oxygen saturation and that a urinalysis could not be done on the weekend. In a subsequent interview, the LPN who documented the nursing notes could not recall the resident’s oxygen saturation level that prompted oxygen therapy, did not remember how often rounding was done to ensure oxygen was in place, and acknowledged that an SpO2 of 86% on room air would not be considered stable, but could not explain why the resident was documented as stable and without oxygen at the time of EMS departure. Facility policies required respiratory assessments to include pulse oximetry readings and documentation of prescribed interventions and responses, and required oxygen tubing to be kept off the floor.
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