Failure to Administer Oxygen Therapy per Physician Order and Maintain Sanitary Respiratory Equipment
Penalty
Summary
Staff failed to administer oxygen therapy according to the physician's order and did not maintain respiratory equipment in a sanitary manner for one resident. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, unspecified chronic bronchitis, and hypoxemia with dependence on supplemental oxygen, had a physician's order for oxygen at two liters per minute (LPM) via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set between one and one and a half LPM, which did not match the physician's order. Additionally, a nebulizer mask used by the resident was found hanging unbagged and exposed to the environment, with a date indicating it had not been changed in accordance with facility policy. The facility's policy required that nebulizer tubing and delivery devices be changed every 72 hours or as needed if soiled, and that delivery devices be kept covered in a plastic bag when not in use. Interviews with the DON and Regional Nurse Consultant confirmed these findings.