Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care and services for three residents who were receiving oxygen therapy. Observations revealed that the nasal cannula oxygen tubing for all three residents was touching the floor, which was confirmed by staff during interviews. Additionally, for two of the residents, the facility did not follow the physician's orders regarding the prescribed oxygen flow rates. Specifically, one resident was observed receiving oxygen at a rate different from the physician's order, and another resident's oxygen therapy was not administered as ordered for their respiratory condition. Medical record reviews indicated that the affected residents had care plans and physician orders specifying the need for continuous oxygen therapy due to conditions such as oxygen desaturation and respiratory acidosis. The care plans also included interventions to administer oxygen as ordered and to monitor oxygen saturation levels. Despite these documented needs and orders, the facility did not ensure that the oxygen therapy was provided according to the physician's instructions, nor did it maintain the cleanliness and safety of the oxygen delivery equipment as required by facility policy.