Failure to Change Oxygen Tubing and Maintain Water Reservoir for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring continuous oxygen therapy. Specifically, staff did not change the resident's oxygen tubing according to the facility's policy, which requires weekly changes and documentation in the electronic health record. Observations over several days showed that the oxygen tubing in use was dated more than a week prior, indicating it had not been changed as required. Additionally, the oxygen concentrator's water reservoir was found empty on multiple occasions, despite the need for it to be filled to ensure proper humidification during oxygen therapy. The resident involved had a history of chronic obstructive pulmonary disease (COPD), pneumonia, and hypokalemia, and was assessed as having severe cognitive decline. Orders were in place for continuous oxygen via nasal cannula, with specific parameters for titration and monitoring. Interviews with facility staff confirmed that nursing staff were responsible for changing tubing and maintaining the water reservoir, but these tasks were not completed as required, resulting in a failure to follow professional standards of practice for respiratory care.