Failure to Provide Humidification and Proper Oxygen Tubing Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who required oxygen therapy. Observations revealed that humidified water bottles were not attached to oxygen concentrators for these residents, and nasal cannulas or oxygen tubing were not dated as required. In several instances, oxygen tubing was found lying on the floor, and portable oxygen tanks were left free-standing without proper stands or containers. These deficiencies were noted despite physician orders and facility policy specifying the need for humidification at certain flow rates, regular tubing changes, and proper labeling. One resident with a history of COPD, respiratory failure, and dependence on supplemental oxygen was observed multiple times without a humidified water bottle attached to the concentrator and with undated nasal cannula. During care, this resident was laid flat and had her oxygen removed, resulting in visible shortness of breath. Another resident, who did not have a physician order for oxygen, was found using an oxygen concentrator without a humidified water bottle and with undated nasal cannula. Additional residents with diagnoses including acute respiratory failure and CHF were also observed using oxygen without humidification and with undated tubing. Interviews with staff, including the DON and LPN, confirmed that nurses are responsible for attaching humidified water bottles and dating nasal cannulas, and that portable oxygen tanks should not be left free-standing. The facility's own policy requires weekly tubing changes, dating of tubing, and the use of humidification as clinically indicated. Despite these policies and staff expectations, the required procedures were not consistently followed for the residents reviewed.