Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide necessary respiratory care and services for a resident with chronic obstructive pulmonary disease, systemic lupus erythematosus, and type 2 diabetes mellitus. The resident had a physician's order for oxygen at two liters per minute and for oxygen tubing and humidifier to be changed weekly. During observation, the resident's nasal cannula tubing was found touching the floor while in use, and an additional oxygen mask and tubing were left on top of an overbed table. The oxygen cannula was not dated to indicate when it was last changed, and the unused oxygen equipment was not stored in a dated plastic bag as required by facility policy. Interviews with the Quality Assurance Nurse and the DON confirmed that oxygen supplies should be dated, changed every seven days, and stored in a dated plastic bag when not in use. Both acknowledged that the resident's oxygen equipment was not managed according to these protocols, and that the undated and improperly stored supplies had the potential to cause respiratory infection. Review of the facility's policy confirmed the requirements for changing and storing oxygen equipment, which were not followed in this instance.