Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to five residents who required oxygen therapy, as evidenced by multiple deficiencies in the handling and administration of respiratory equipment. Observations revealed that several residents' nasal cannulas were not properly stored when not in use. Specifically, nasal cannulas were found coiled around oxygen tanks or attached to wheelchairs without being bagged, with the prongs exposed and touching surfaces. This was observed for multiple residents, and staff interviews confirmed that the cannulas should have been bagged to prevent respiratory infection, but this was not done during routine rounds. Additionally, the facility did not ensure that a humidifier bottle attached to an oxygen concentrator for one resident contained water. The humidifier bottle was observed to be empty while the resident was receiving oxygen therapy. Staff acknowledged that they had not checked the water level during their rounds, despite the purpose of the humidifier being to moisten the air and prevent irritation to the nasal passages. The facility also failed to display an "Oxygen In Use" sign outside the room of a resident receiving oxygen therapy. Staff interviews indicated that such signage is required to alert staff and visitors to the presence of oxygen and the associated fire hazards. Review of facility policies confirmed the requirements for proper storage of nasal cannulas, maintenance of humidifier water levels, and the posting of oxygen use signage, but these procedures were not followed as observed during the survey.