Failure to Provide Ordered Humidification and Proper Labeling for Oxygen Therapy
Penalty
Summary
Staff failed to follow physician orders and professional standards for three residents requiring oxygen therapy. Specifically, the oxygen concentrators for these residents did not have humidifiers attached as ordered, and the oxygen tubing and humidifier bottles were not labeled or dated according to the prescribed schedule. Observations in the residents' rooms confirmed the absence of humidifiers and missing labels and dates on the equipment. Physician orders for all three residents required weekly changes of humidifiers and nasal cannulas, with proper labeling and dating, but these were not carried out as directed. Interviews with facility staff, including CNAs and an RN, revealed a lack of knowledge and understanding regarding the process for adding humidity to the concentrators and the importance of labeling and dating the equipment. The Director of Nursing confirmed that the concentrators in use were not capable of adding humidity, which was required by the physician orders. These failures resulted in the facility not meeting professional standards of quality for the affected residents.