Failure to Ensure Safe and Appropriate Oxygen Therapy and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents receiving oxygen therapy, as evidenced by multiple deficiencies in following physician orders and maintaining equipment cleanliness. For one resident with diagnoses including anemia, heart failure, and multiple sclerosis, the oxygen flow rate was not consistently maintained as ordered by the physician. Observations showed the oxygen was set at the correct rate at times, but at other times it was set lower than ordered. Additionally, the oxygen tubing was not labeled or dated to indicate when it had been changed, contrary to facility expectations and policy. Another resident with a complex medical history, including COPD and congestive heart failure, was observed using an oxygen concentrator that was visibly dirty, with a fluffy brown, gray, and white substance covering the filter area and the machine itself over several days. The facility's policy required weekly cleaning of the concentrator's exterior by housekeeping and regular maintenance by the oxygen provider, but these procedures were not followed, resulting in unsanitary equipment use. A third resident with COPD and other chronic conditions had inconsistent oxygen orders and administration. The care plan indicated the resident sometimes removed the nasal cannula and changed the oxygen setting independently. Observations and interviews revealed that nursing staff did not consistently follow the care plan or physician orders regarding oxygen flow rates and documentation. The DON confirmed expectations for staff to follow orders, label and date tubing and humidification bottles, and ensure proper administration, but these practices were not consistently implemented.