Failure to Administer and Maintain Oxygen and Nebulizer Equipment per Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), anxiety, and dementia was observed receiving supplemental oxygen at a flow rate of 3 liters per minute (L/min) via nasal cannula, despite the active physician order specifying oxygen at 2 L/min as needed. Multiple observations confirmed the oxygen was being administered at the higher rate without any documented assessment or physician notification to justify the change. The resident's medical record did not contain documentation supporting the increased oxygen flow, and the most recent vital signs indicated an oxygen saturation of 97% on room air, with no evidence of a clinical need for the higher oxygen rate. Additionally, the oxygen tubing in use was found to be dated over a month prior to the observation, exceeding the facility's protocol for changing tubing every two weeks. Staff interviews confirmed the tubing was out of date and that the protocol for timely replacement was not followed. The resident was unaware of the oxygen concentration being administered and reported feeling more short of breath recently. Further observations revealed that the resident's nebulizer equipment, including the medication chamber and mouthpiece, was left resting directly on the nightstand without a protective barrier and was not stored in a sanitary manner as required by facility policy. Staff confirmed that the nebulizer equipment should have been cleaned, dried, and stored in a plastic bag after each use, but this was not done. Facility policies for both oxygen and nebulizer care were not followed, resulting in deficiencies in both the administration and maintenance of respiratory equipment.
Plan Of Correction
The facility will ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences. For Resident #65, the DON and practitioner reviewed the resident's recent oximetry readings and assessed the resident's respiratory status, clarifying the oxygen liter flow ordered. The DON replaced, labeled, and dated the resident's oxygen tubing. The DON placed a barrier under the equipment and ensured a baggie was available to store tubing when not in use, per facility policy. The DNP reviewed the resident's record and completed an assessment with ongoing treatment for a diagnosis of COPD. No noted ill effects. On 4/17/2025, the DON identified those residents who are currently receiving oxygen and audited tubing for accuracy on labeling and to ensure correct storage units to coil and place tubing in a baggie when not in use. One of three was noted to have out-of-date oxygen tubing. The tubing was changed and labeled correctly. The DON also audited care plans for accuracy, and all three were up to date. The DON verified orders on all residents receiving oxygen to determine accuracy on the rate of flow the resident is receiving. The ADON obtained the current list of residents receiving nebulizer treatments. In each unit where these residents reside, the DON ensured nurses had proper cleaning supplies, an area to allow equipment to dry, and proper storage containers for nebulizer equipment. To prevent oxygen tubing from becoming outdated, ensure it is stored in a sanitary manner, and ensure oxygen is administered per physician order, the following has been completed and/or initiated: On 4/18/2025, the DON and ADON reviewed the following policies and deemed them appropriate with evidence-based practices: 1) Cleaning and Disinfecting Nebulizers Policy, 2) Oxygen Use and Set-up Policy, 3) Medication Administration Policy. On 5/1/2025, all nurses currently working in the facility received 1:1 education on the following: 1) Cleaning and Storage of oxygen tubing & nebulizer equipment, 2) 5 Rights of Medication Administration with a focus on checking the order to assure that oxygen is being administered at the ordered liter flow, 3) Hand Hygiene with a focus on during medication administration. For those employees who are casual/student status, on vacation, or on LOA, training will be completed before/during their next scheduled shift. The DON and ADON created a Relias education module and post-test for all licensed nursing staff, including a review of the Cleaning and Disinfecting Nebulizer Policy and Oxygen Use and Set-up Policy. The focus was on storing oxygen tubing, cleaning equipment after each use, changing oxygen tubing, and how/what to use to clean equipment. They also created a Relias education module and post-test for all CNAs, emphasizing storing tubing when not in use. 1:1 education was provided to AMA and NAA staff on the delivery of oxygen tubing and humidifier bottles, with an emphasis on: - Placing new tubing themselves and not delegating it out to another staff member. - Reapproaching the resident if unable to apply when they first attempt. - Reviewing the Oxygen Use and Set-Up Policy. To ensure the education and changes implemented are followed, monitoring has been implemented to ensure sustainability of compliance: - DON/ADON or designee will complete audits of oxygen administered per physician order and labeling of oxygen tubing for accuracy, weekly for 2 months, and with random audits for 1 month. - Storing of equipment in a sanitary manner will be audited 2 times per week for one month, weekly for one month, and randomly for one month. The facility will schedule follow-up evaluations to ensure that these practices are maintained over the long term and that any trends are addressed promptly. The DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. The DON/ADON will be responsible for attaining and sustaining overall compliance with this plan of correction.