MACON, GA-ZEBULON PARK HEALTH & REHABILITATION

Based on observations, staff interviews, record review, and review of the facility policy titled Use of Oxygen Therapy , the facility failed to ensure that one (1) of 13 residents (R) R#17 was administered oxygen (O2) therapy in accordance with the Physician’s order. The deficient practice had the potential to affect the overall respiratory status for residents receiving oxygen therapy.

Findings include:
Review of the facility policy titled Use of Oxygen Therapy review date 12/30/2022, revealed: Under Intent: To ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. Under Guideline: Physician’s order for oxygen should be obtained and include: oxygen with liter (L) flow or percentage ordered.

Review of R#17 diagnoses included but not limited to acute respiratory failure with hypoxia, congestive heart failure (CHF), obstructive sleep apnea, and dependence on other enabling machines and devices.

Review of R#17 Quarterly Minimum Data Set (MDS) revealed:
Section C (Cognitive Pattern) Brief interview of Mental Status (BIMS) score of 15 indicating no cognitive deficit.

Review of #17 Care Plan revealed respiratory changes related to CHF and respiratory failure and the need for O2. Interventions include administer medications and/or treatment as ordered and O2 at 4 L via nasal canula.

Review of R#17 Physician’s orders revealed:

Oxygen: nasal cannula at 4 L per minute nasally check every shift.

Review of R#17 Medication Administration Record (MAR) revealed: MAR checked 6/23/2023 and the MAR showed R#17’s O2 concentrator was checked on day shift and night shift.

Observation on 6/20/2023 at 2:36 p.m., revealed R#17 was asleep in bed with O2 per nasal cannula at 5L.

Observation On 6/21/2023 at 8:33 a.m. revealed R#17 was in the bed and had just finished breakfast and his call light was on. Certified Nursing Assistant (CNA) came in at 8:35 a.m. R#17 had on BiPAP and his O2 had not been taken off and changed to his O2 concentrator. R#17’s O2 concentrator was set on 5L per minute.

The Licensed Practical Nurse (LPN) LPN AA checked his O2 concentrator and verified the O2 concentrator was set at 5L per minute and changed it to 4L per minute.

Interview on 6/20/2023 at 9:00 a.m. with Medication Technician (Med Tech) Med Tech BB revealed O2 concentrators are maintained every shift, if a nasal cannula hits the floor, it is thrown away and replaced with a new one, tubing is stored in a plastic bag.

Interview on 6/21/2023 at 9:10 a.m. with LPN CC revealed O2 machines are checked for O2 flow per MAR, scheduled tube changes per MAR, O2 tubes are changed monthly or as needed (PRN).

Interview on 6/21/2023 at 11:38 a.m. with Director of Nursing (DON) revealed it is the nurse’s responsibility to check the Physician’s orders on the MAR on every shift to verify that the O2 is at the right liter.