Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide proper care and treatment for residents receiving oxygen therapy. Two residents with orders for continuous oxygen via concentrator were observed with thick grayish substance buildup on the filters of their oxygen concentrators, despite physician orders and facility policy requiring weekly cleaning or changing of the filters. The infection preventionist was unsure who was responsible for this task, and the DON stated it should have been done weekly by nurses or central supply staff. Both residents had significant respiratory diagnoses, including acute respiratory failure, hypoxia, pneumonia, and COPD, and were observed in bed on oxygen therapy at the time of the deficiency. Additionally, another resident with a diagnosis of COPD was administered oxygen at a rate of 5 liters per minute, contrary to the physician's order for 2 liters per minute via nasal cannula. The LVN present acknowledged awareness of the correct order but did not adjust the oxygen flow. The resident's care plan also specified that oxygen should be administered as ordered. Facility policy required verification of physician orders prior to oxygen administration, but this was not followed in this instance.