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Based on clinical record review, hospital documentation and interviews for one of three sampled patients (Patient#6) receiving oxygen in the ED, the hospital failed to ensure that a portable oxygen tank had a sufficient amount of oxygen for patient use resulting in a change in the patient's oxygen saturation level requiring intubation.

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Based on clinical record review, facility documentation and interviews for one of three sampled patients (Patient#6) receiving oxygen in the ED, the hospital failed to ensure that a portable oxygen tank had a sufficient amount of oxygen for patient use resulting in a change in the patient's oxygen saturation level requiring intubation. The findings include:

Patient #6 presented to the ED on 5/31/18 arrival time 5:38PM, with a two day history of shortness of breath, vomiting and cough. The patient's past medical history included Chronic Obstructive Pulmonary Disease (COPD), chronic hypoxic respiratory failure, and was on continuous 6 liters of oxygen via nasal cannula at home. Patient #6 was placed on a stretcher in the emergency department hallway and received oxygen therapy via a portable oxygen tank supplied by the hospital.

Vital signs documented at 5:43PM included Blood Pressure 172/88 mm/Hg, Pulse 102 bpm, Respiration 32 and oxygen saturation (SaO2) level 94% on 6 liters per minute (LPM) oxygen via nasal cannula. A pulmonary assessment note by RN#3 at 5:50PM identified diminished bilateral breath sounds, expiratory wheezing and anxious. The note also identified that the patient was removed from a non-rebreather (initiated by EMS) oxygen delivery system and placed on a nasal cannula at 6LPM, patient tolerating well at this time.

Review of the clinical record and interviews failed to identify that the portable oxygen tank level was checked when the oxygen delivery via non-rebreather mask (which requires a minimum flow of 10 LPM) was changed to the nasal cannula.

In an interview on 7/23/18 at 3:45PM, RN#3 identified she was the primary nurse for Patient #6 and recalled the shift was busy. RN#3 identified the patient arrived by ambulance and the emergency medical staff (EMS) had placed the patient on a stretcher and connected the non-rebreather mask to the (hospital's) portable oxygen tank. After assessing the patient and physician notification, RN#3 changed the method of oxygen delivery from the non-rebreather to nasal cannula providing oxygen at 6 LPM at approximately 5:50 PM. RN#3 identified when she had inserted the peripheral intravenous catheter about 7:30PM, the patient complained of shortness of breath and she went to get a monitor to assess the patient's vital signs as well as a medication. RN#3 identified shortly thereafter Person#2 had yelled that Patient #6 required help at which point other staff responded and the patient was immediately placed into an exam room for further evaluation. RN#3 identified she did not check the oxygen tank level prior to putting the nasal cannula on and was not aware of the tank contents at that time. RN #3 identified that at the time, there was no one designated as responsible for checking oxygen tank levels.

A nursing note by RN#3 at 7:30PM identified patient experiencing worsening shortness of breath, SaO2 level dropped to 80% and portable oxygen tank found to be empty. The note further identified the patient was moved to an exam room and placed on a non-rebreather mask, MD present and respiratory called to place patient on BiPAP with nebulizer treatment.

Review of the ED notes identified that although Patient #6's oxygen saturation level improved to 98% with the use of a the BiPAP, a decision was made to intubate the patient at 10:30PM due to respiratory symptoms not responding to respiratory treatments and a diagnosis of respiratory acidosis. The patient was subsequently admitted to ICU intubated for ventilator support. Review of a discharge summary dated 6/23/18 identified that Patient #6 was successfully extubated and discharged to a short term rehabilitation facility.

Interview with PA #1 on 7/20/18 at 1:40 PM identified that she examined Patient #6 and ordered oxygen via nasal cannula at 6 LPM and a respiratory treatment. PA #1 determined the patient to be stable and would be put in a room as soon as one became available. PA #1 identified that an empty oxygen tank may have been a contributing factor for the decision to intubate the patient.

In an interview on 7/20/18 at 11:50PM, MD#4 identified Patient #2 was initially seen by PA#2, recalled that the shift was extremely busy and exam rooms were occupied therefore the patient was in the hallway until a room was made available. MD#4 recalled that Person#2 asked for Patient #6 to be checked because he/she had difficulty breathing. MD#4 identified that the patient's SaO2 level was low and that he/she was receiving oxygen via the portable tank. MD#4 identified the patient was taken to an exam room for further evaluation and treatment with respiratory therapy support. In addition, MD#4 identified he had been informed that the tank had ran out of oxygen.

Interview with the Director of Quality on 7/24/18 at 2:50PM identified that at the time of the incident, there was no process for checking oxygen tank levels in the emergency department. The Director of Quality identified that according to the ED Nurse Manager, the person who initiated the use of the tank would be responsible for checking the contents of the portable oxygen level. As a result of the incident, the hospital initiated a process for monitoring oxygen tank levels.

Tour of the emergency department on 8/29/18 identified that all 25 patients currently receiving care and treatment were in examination rooms equiped with wall mounted oxygen delevery systems. Interview with the Manager of the emergency department on 8/29/18 at 12:20 PM identified that there are occasions when a patient would be placed on a stretcher in the hallway. However, the current practice would be for any patient requiring oxygen to be placed in an examination room, not the hallway.