Failure to Properly Administer and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who were receiving oxygen therapy. For one resident with COPD and oxygen dependence, surveyors observed that the oxygen tubing was crimped, preventing oxygen from reaching the resident, and the concentrator filter was caked with dust over several days. The humidifier bottle was not changed as ordered, and there was no specific signage indicating oxygen use in the room. The Director of Nursing (DON) and Administrator confirmed the dirty filter and acknowledged that the filter should have been cleaned and that the tubing should not have been crimped. Another resident with COPD was observed multiple times receiving oxygen at a flow rate of 3.5 liters per minute, despite a physician's order for 2 liters per minute. The DON confirmed that the oxygen should have been set at 2 liters per minute and that only a physician could authorize a change in flow rate. The DON also stated that nurses were expected to check oxygen settings at the beginning of each shift, but the incorrect flow rate persisted across several observations. A third resident with Alzheimer's disease and COPD was found receiving oxygen at higher flow rates than ordered, with the oxygen concentrator set at 4 liters per minute and later at 3 liters per minute, despite an order for 2 liters per minute as needed for shortness of breath or low oxygen saturation. Nursing staff confirmed the incorrect settings and adjusted the flow rate during the survey. Additionally, there was no signage on the resident's doorway to indicate oxygen therapy was in use, as required by facility policy. The facility also lacked a specific Oxygen Safety Policy, despite referencing it in their procedures.