Failure to Follow Oxygen Administration Orders and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to the physician's order for oxygen administration for a resident with multiple diagnoses, including acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. The resident was observed receiving oxygen at one liter per minute via nasal cannula, contrary to the physician's order for two liters per minute. This discrepancy was acknowledged by the Director of Nursing, who confirmed that oxygen is considered a medication and must be administered as per the physician's order. Additionally, the facility did not follow its policy regarding the maintenance of oxygen equipment. The oxygen tubing, dated March 23, 2025, was not changed weekly as required, and the humidifier bottle was nearly empty with no bubbles, indicating a lack of moisture being provided to the resident. The Director of Nursing acknowledged these oversights, which are contrary to the facility's policy that mandates regular checks and maintenance of the oxygen equipment to ensure proper infection control and adequate moisture delivery to residents.