Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and hypoxia. On two separate occasions, oxygen tubing was observed lying unbagged and not in use, with the oxygen concentrator left on and releasing oxygen while the resident was not present or not wearing the nasal cannula. Staff interviews confirmed that oxygen should be turned off when not in use and tubing should be bagged, but a bag was not available in the resident's room. The facility's policy required oxygen to be turned on only at the time of application and placed on the resident, but this was not followed. Additionally, the resident was found in bed with labored breathing, poorly positioned with her chin tucked to her chest, and without access to her oxygen tubing, which was out of her reach. The resident was cognitively impaired, required assistance with personal care, and had no documented refusal of care. Staff confirmed the resident could not have moved the tubing herself or accessed her wheelchair, indicating a lack of appropriate monitoring and intervention to ensure her respiratory needs were met.