Failure to Replace Oxygen Cannula as Required by Policy
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the timely replacement of oxygen delivery equipment for a resident with significant respiratory needs. Specifically, the policy required that the oxygen cannula or mask and the disposable humidifier be changed at least every seven days. However, for one resident with diagnoses including acute respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD), the nasal cannula in use was observed to be dated more than seven days prior, indicating it had not been replaced as required. This was confirmed during observations and interviews with facility staff, including the Director of Staff Development and the Director of Nursing, who both acknowledged the cannula should have been changed weekly to prevent infection. The resident in question had moderate cognitive impairment and required varying levels of assistance with daily activities, including being dependent for personal hygiene and toileting. The resident had a continuous oxygen order via nasal cannula, with specific orders to change the cannula and humidifier every Sunday. Despite these orders and the facility's policy, the cannula remained in use beyond the prescribed timeframe, as verified by the date marked on the equipment and staff interviews. The failure to replace the nasal cannula as scheduled constituted a breach of the facility's infection control practices.