Failure to Ensure Proper Oxygen Therapy Setup
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and difficulty walking was not provided with safe and appropriate respiratory care as required. During an observation, the resident's oxygen concentrator tubing was found disconnected from the humidification bottle, which is necessary to add moisture to the oxygen. The resident had the nasal cannula in place but was not receiving any oxygen flow at the time of the observation. The facility's policy on oxygen therapy did not address the use of a humidification bottle, and the tubing was immediately reattached by a Licensed Practical Nurse upon discovery. Interviews revealed conflicting accounts regarding how the tubing became disconnected. The resident stated she does not remove the tubing from the concentrator to the humidification bottle, while the Nursing Home Administrator indicated that the resident sometimes disconnects the tubing while using the restroom. Regardless, the deficiency was identified as staff failed to ensure the oxygen equipment was properly set up and functioning, resulting in the resident not receiving prescribed oxygen therapy.