Failure to Follow Oxygen Administration Policies for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following established policies and procedures for oxygen administration. One resident with a diagnosis of COPD was observed receiving continuous oxygen at six liters per minute via nasal cannula, which exceeded the physician's order of 2-4 liters per minute as needed to maintain oxygen saturation above 90%. There was no documentation or assessment of the resident's oxygen use that morning, and staff did not report the increased oxygen level or assess the resident's condition as required. Facility staff, including an LVN and RN Supervisor, acknowledged that the oxygen was set incorrectly and that the resident's condition and oxygen use had not been properly monitored or documented. Another resident, admitted with acute respiratory failure and pleural effusion, was observed using an unlabeled nasal cannula for oxygen delivery. The tubing was not labeled with the date as required by facility policy, which mandates that oxygen tubing be changed and labeled every seven days and as needed. Staff confirmed that the tubing should have been labeled to prevent infection, and the physician's order specified regular changes and labeling of the oxygen equipment. These failures were directly observed and confirmed through staff interviews and record reviews.