Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not properly labeling oxygen tubing with the date it was changed, not following the physician's order for the prescribed oxygen flow rate, and not developing or implementing a comprehensive, person-centered care plan for oxygen therapy. During observation, a resident was found using a nasal cannula connected to a humidifier bottle and oxygen concentrator set at 4 liters per minute (LPM), while the physician's order specified 2 LPM via nasal cannula. The oxygen tubing was not labeled with the date or time of the last change, and the nurse on duty was unable to confirm when the tubing was last changed or the correct flow rate for the resident's oxygen therapy. Review of the resident's medical record revealed orders for weekly oxygen tubing changes and continuous oxygen at 2 LPM, but there was no order for the use of a humidifier bottle. Documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not indicate the use of humidification, and the care plan lacked a focus on oxygen therapy with specific goals and interventions. The Director of Nursing confirmed these deficiencies, noting that the oxygen tubing should be labeled and that oxygen therapy should be addressed in the care plan.