Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, resulting in deficiencies related to the administration and management of oxygen therapy. For one resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, surveyors observed on multiple occasions that the resident's oxygen tubing was not connected to the concentrator as ordered, and the tubing was undated. The resident's medical record included a physician's order for oxygen at 3 liters per minute via nasal cannula and a weekly tubing change, but the tubing was found lying on the floor, not attached, and without documentation of when it was last changed. Nursing staff confirmed that the tubing should be connected, changed weekly, and dated, but these practices were not followed. For another resident with COPD and anxiety disorder, who was alert and required setup assistance for daily care, the facility failed to ensure continuous oxygen therapy during the resident's leave of absence (LOA) from the facility. The resident reported going out to the store by taxi every few weeks and stated that portable oxygen was not provided during these outings, despite a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. Staff interviews and documentation review confirmed that the resident had left the facility multiple times without portable oxygen, and there was no evidence in the medical record that portable oxygen was provided or that refusals were documented. Facility policy required oxygen to be administered according to physician orders, with weekly tubing changes and proper documentation. Both residents were observed to have intact cognition and were able to communicate their needs. However, the facility did not adhere to its own policies or physician orders regarding oxygen therapy, resulting in lapses in respiratory care and services for these residents.