Failure to Follow Oxygen Therapy Protocols for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care services for two residents by not following established protocols for oxygen therapy. For one resident with COPD and heart failure, the physician ordered oxygen at four liters per minute as needed, and the care plan required humidification to prevent symptoms of poor oxygen absorption. Observations revealed that the resident's oxygen humidifier bottle was nearly empty on one occasion and completely empty on another, despite the resident using oxygen continuously and stating a need for humidification. A nurse confirmed the humidifier bottle was empty and acknowledged that lack of humidification could lead to nasal dryness and bleeding. The Director of Nursing stated that humidifier bottles should be checked daily and changed before running out, in line with facility policy. For another resident with respiratory failure and a history of fractures, the physician ordered continuous oxygen therapy via nasal cannula. The facility's policy required that nasal cannulas be changed every seven days and labeled with the date of change to prevent infection. During an observation, the resident's nasal cannula was not labeled with the date it was last changed. A nurse confirmed the cannula should be labeled and changed weekly, and the DON reiterated the importance of labeling to prevent bacterial growth and respiratory infections. The facility's own policies and procedures for oxygen therapy were not followed in both cases. The humidifier bottle for one resident was allowed to run empty, and the nasal cannula for another resident was not labeled as required. These lapses were confirmed by staff interviews and direct observation, and were contrary to the facility's written protocols for respiratory care.