Failure to Provide Safe and Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring continuous oxygen therapy. For one resident with anemia and heart disease, staff did not follow physician orders to monitor oxygen levels every shift, clean the oxygen concentrator filter weekly, or replace oxygen tubing and nasal cannula every seven days. Observations revealed the resident's oxygen tubing was cloudy and unlabeled, the nasal area and skin behind the ears were irritated and red, and there was no sterile water attached to the concentrator for humidification. Staff were unaware of the missing humidification and labeling, and the oxygen concentrator filter was found to be dirty with visible dust buildup. For another resident with interstitial pulmonary disease and dementia, staff failed to ensure continuous oxygen delivery as ordered. The resident was observed multiple times with an empty portable oxygen tank, resulting in an oxygen saturation reading of 86%. The resident expressed feeling unwell, and staff were unaware that the oxygen tank was empty. Physician orders required verification that oxygen saturation remained above 92% during transfers and showers, but this was not monitored or maintained. These failures were identified through direct observation, interviews, and record review.