Failure to Properly Store Nasal Cannulas for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that nasal cannulas used for oxygen therapy were properly stored when not in use for three residents. Observations revealed that one resident's nasal cannula was left spread out on top of the bed, another resident's nasal cannula was found on the floor, and a third resident's nasal cannula was placed on a side table with the prongs touching the surface. In each case, the nasal cannulas were not bagged as required by facility policy and professional standards of practice. The residents involved had significant medical needs requiring oxygen therapy, including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and conditions such as intracranial hemorrhage and seizures. Documentation confirmed that these residents had physician orders for continuous oxygen therapy and care plans reflecting their respiratory needs. Despite these documented requirements, staff did not consistently follow procedures to prevent contamination of respiratory equipment. Interviews with staff and residents confirmed that the nasal cannulas were not stored in plastic bags when not in use, and staff acknowledged that this practice was necessary to prevent infection. The facility's own policy specified that oxygen cannulas and tubing should be kept in a plastic bag when not in use, but this was not followed, resulting in a failure to meet professional standards and the residents' care plans.