Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A resident with a history of acute and chronic respiratory failure, hypoxia, type 2 diabetes mellitus, and falls was admitted and readmitted to the facility. The resident required substantial to maximal assistance with daily activities and was receiving oxygen therapy as part of their care plan. Physician orders specified that oxygen should be administered at two liters per minute via nasal cannula, with titration up to three liters per minute to maintain oxygen saturation above 90%. The orders also required weekly changes of oxygen tubing, with labeling of the date and time, and the use of a humidifier when oxygen was administered at three liters per minute or more. During an observation, the resident was found to be receiving oxygen at six liters per minute via nasal cannula, which exceeded the physician's order. The oxygen tubing in use did not have a label indicating the date and time it was last changed, and the humidifier attached to the oxygen machine was empty. Staff interviews confirmed that the resident was receiving oxygen at a higher rate than ordered, the tubing was not labeled as required, and the humidifier was not filled. Staff acknowledged that these actions did not comply with physician orders or facility policy. The facility's policy on oxygen administration required licensed staff to follow physician orders, change and label oxygen tubing weekly, and ensure the humidifier was full when oxygen was administered at three liters per minute or more. The deficiencies observed included failure to administer oxygen at the ordered rate, failure to label and change oxygen tubing as required, and failure to maintain the humidifier, all of which were confirmed by staff and documentation review.