Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified when a resident who had a physician's order for continuous oxygen at two liters per minute via nasal cannula was observed with their oxygen tubing on the floor and the cannula not attached to their nose. The tubing was found under the resident's body, with one end connected to the oxygen concentrator, and the other end not in use. This observation was confirmed by a Licensed Vocational Nurse, who acknowledged that the tubing was contaminated and not in accordance with professional standards of practice. The resident involved had a history of right femur fracture, aphasia, and urinary tract infection, and was assessed as able to make needs known but unable to make medical decisions. Facility policy required the nasal cannula to be properly placed in the resident's nose and secured, and CDC guidelines indicated that floors can become rapidly contaminated. The Director of Nursing confirmed that staff are required to implement physician orders for oxygen administration and acknowledged the potential for infection if tubing contacts the floor and for desaturation if the cannula is not attached.