Failure to Ensure Professional Standards in Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice were implemented for residents receiving oxygen therapy. For three residents reviewed, there were multiple instances where oxygen was administered without a current physician's order, and facility staff were inconsistent in following the facility's policy regarding the changing and dating of oxygen tubing. Observations revealed that oxygen tubing was found on the floor on several occasions, and staff responses to this situation varied, with some staff cleaning and reusing the tubing, while others replaced it. There was also confusion among staff regarding the frequency of tubing changes and the proper documentation required. For one resident with COPD, oxygen was observed in use during the day, despite the physician's order specifying nighttime use only. The oxygen tubing was repeatedly found on the floor, and staff provided conflicting accounts of how to handle such situations. Another resident with chronic respiratory failure reported that their oxygen tubing had not been changed since admission, and observations confirmed that the tubing was undated. The oxygen flow meter settings did not match the physician's order, and staff were unclear about the correct procedures for changing and dating the tubing. A third resident was observed using oxygen without a current physician's order, as the previous order had been discontinued and not renewed. The care plan did not address oxygen use, and staff were unaware of the need for an order or the appropriate care plan updates. Interviews with nursing staff and management revealed a lack of clarity regarding facility policy and expectations for oxygen administration and tubing changes, as well as inconsistent documentation practices.