Failure to Provide Proper Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring oxygen therapy. For one resident with chronic obstructive pulmonary disease (COPD) and moderate cognitive impairment, observations revealed that the humidifier bottle attached to his oxygen concentrator was empty while he was receiving oxygen via nasal cannula. The resident reported nasal dryness and could not recall when the bottle last contained water. The assigned LVN admitted to not noticing the empty humidifier during morning rounds and only refilled it after the deficiency was identified. For another resident with COPD and severe cognitive impairment, her nasal cannula, used for nighttime oxygen therapy, was found unbagged and stored directly inside a drawer, with the prongs in contact with other items. The resident confirmed that staff typically removed the cannula in the morning. The LVN acknowledged that the cannula should have been stored in a plastic bag to maintain cleanliness and prevent infection, but had not noticed its improper storage during rounds. Upon discovery, the LVN discarded the unbagged cannula and planned to replace it. Interviews with the DON, Administrator, and ADON confirmed that facility expectations and policy require humidifier bottles to contain water during oxygen administration and nasal cannulas to be bagged when not in use. The facility's policy on oxygen administration specifies the need for humidification to prevent drying of mucous membranes. Despite these expectations, staff failed to ensure proper respiratory care practices for both residents.