Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required oxygen therapy. Observations revealed that one resident had an oxygen nasal cannula improperly placed on her cheek instead of in her nostrils, and the oxygen concentrator's humidifier bottle was empty and not replaced in a timely manner, despite being brought to the attention of an LPN. The same resident was later observed with the humidifier bottle still empty. Physician orders indicated continuous oxygen at a specified flow rate, and the care plan required monitoring and timely replacement of oxygen equipment, which was not followed. Additional deficiencies were noted for two other residents. One resident's oxygen tubing and cannula were stored improperly in a nightstand drawer without a plastic bag, and the humidifier bottle was not changed as scheduled. Another resident was observed receiving oxygen at a higher flow rate than ordered, with a humidifier bottle that was nearly empty and past the scheduled replacement date. Facility policy required humidifier bottles to be changed every seven days and when water levels were low, and for oxygen appliances to be stored in plastic bags when not in use, but these procedures were not followed.