Failure to Provide Ordered Oxygen Therapy and Maintain Oxygen Equipment
Penalty
Summary
The facility failed to ensure that residents received continuous oxygen therapy as ordered by their physicians for two of five sampled residents. One resident with a history of acute respiratory failure, hypoxia, and COVID-19 was observed without an oxygen machine at bedside, despite a physician's order for continuous oxygen at three liters per minute via nasal cannula. The resident confirmed not using oxygen recently, and staff interviews revealed that the physician's order was not followed, with no documented reason for discontinuation or physician notification. Another resident with acute respiratory failure and COPD was also found not wearing the prescribed nasal cannula during observation, despite an active order for oxygen therapy. Additionally, the facility did not ensure that oxygen tubing was dated and changed according to facility policy and physician orders for two residents. One resident's oxygen tubing and bag were observed to be undated, and staff confirmed that the tubing should have been dated and replaced weekly. Another resident's oxygen tubing and bag were found to be dated beyond the required seven-day change interval, indicating the tubing had not been replaced as scheduled. Staff interviews confirmed that central supply was responsible for changing and dating the tubing, and that the failure to do so was not in accordance with facility policy. Record reviews and staff interviews consistently indicated that the facility's policies required oxygen to be administered as ordered by the physician and for oxygen equipment to be dated and changed at specified intervals. Observations and documentation showed that these requirements were not met for multiple residents, with staff acknowledging the lapses in following physician orders and facility protocols for respiratory care and infection prevention.