LAKEWOOD, CO- WESTERN HILLS HEALTH CARE CENTER

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure oxygen was administered at the physician-ordered flow rate to prevent potential complications for 1 (Resident #80) of 3 sampled residents reviewed for oxygen therapy.

Review of a care plan, dated as initiated 07/08/2021, revealed Resident #80 needed oxygen therapy due to shortness of breath from [CONDITION(S)]. A planned intervention was to administer oxygen at 1.5 liters per minute (LPM) continuously.

Observation on 11/07/2022 at 10:30 AM revealed Resident #80 sitting in a wheelchair in their room with a portable oxygen cannister behind the wheelchair. The resident was receiving oxygen via nasal cannula, with the flow rate set at 2.5 LPM, instead of 1.5 LPM as ordered by the physician.

Observation on 11/08/2022 at 2:20 PM revealed Resident #80 was receiving oxygen via nasal cannula, with the flow rate on the resident’s oxygen concentrator set on 3 LPM, instead of 1.5 LPM as ordered by the physician. During an interview at this time, Resident #80 denied ever having adjusted the oxygen flow and stated the nurses took care of that. The resident indicated they were unsure what the oxygen flow rate should be.

Review of the November 2022 Treatment Administration Record revealed RN #3 had initialed the oxygen order to indicate the oxygen was administered as ordered during the day shift on 11/08/2022.

Observation on 11/09/2022 at 2:55 PM revealed Resident #80 was sitting in a wheelchair receiving oxygen at 2.5 LPM via nasal cannula connected to a portable oxygen tank. Review of the November 2022 Treatment Administration Record revealed RN #3 had initialed the oxygen order to indicate the oxygen was administered as ordered during the day shift on 11/09/2022.

During an interview on 11/10/2022 at 9:10 AM, RN #3 stated nursing staff should check on residents who received oxygen therapy at the beginning of their shift and ensure the resident was wearing the nasal cannula correctly, ensure oxygen tanks were full, and check the flow rate on the oxygen concentrator/tank. RN #3 stated that most of the time, he looked at the physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #3 stated he thought Resident #80’s physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #3 stated he kept Resident #80’s oxygen at 2.5 LPM and had not informed the physician about the change in flow rate. He stated he did not request an order to change the flow rate but should have.

During an interview on 11/10/2022 at 8:03 AM, LPN #2 verified Resident #80’s oxygen flow rate was set to deliver oxygen at 3 LPM. LPN #2 stated she checked on Resident #80 that morning and that a certified nursing assistant (CNA) obtained the resident’s vital signs. She indicated the resident had since been sleeping, and she had not checked the resident’s oxygen setting nor physician orders. LPN #2 stated nursing staff should always check residents’ physician orders; however, she stated she could not remember the last time she looked at Resident #80’s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .