Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not changing the resident's oxygen tubing weekly as required by facility policy and by maintaining an incomplete physician's order for oxygen therapy. During observation, the resident was found using a nasal cannula with a date label indicating it had not been changed within the required seven-day period. Staff interviews confirmed that the tubing should have been changed weekly to maintain infection control, and failure to do so could lead to infection. Additionally, a review of the resident's physician order for oxygen therapy revealed that the order lacked specific parameters, such as whether the oxygen was to be administered routinely or as needed, and did not provide clear instructions for when to start or stop oxygen. Both the RN Supervisor and the DON acknowledged that the order was incomplete and that oxygen, considered a medication, requires a complete and clear order to ensure safe administration. The facility's policies confirmed the need for weekly tubing changes and complete physician orders for oxygen therapy.