Failure to Maintain Oxygen Humidifiers and Equipment for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with severe cognitive impairment and diagnoses including Alzheimer's Disease and heart failure, observations on two consecutive days revealed that the oxygen humidifier bottle attached to her concentrator was empty while she was receiving oxygen via nasal cannula. Facility records indicated that the oxygen tubing and water were to be changed weekly and as needed, and the care plan specified continuous oxygen therapy. The Director of Nursing confirmed that nurses were responsible for refilling humidifiers, which should occur on Sundays, but the humidifier was found empty during the survey. For another resident with moderate cognitive impairment and diagnoses including diabetes and heart failure, observations showed that her oxygen humidifier bottle was low on water and her oxygen concentrator was beeping on two occasions. The resident reported discomfort from a dry nose and recalled nearly running out of water in the humidifier. Staff interviews revealed that daily checks of humidifier bottles were performed, but the responsibility for refilling them was assigned to Sunday night staff. Facility policy required periodic re-checks of the water level in humidifying jars, but this was not consistently followed, resulting in inadequate respiratory care for the residents.