Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary care and services for three residents receiving oxygen therapy by not adhering to professional standards of practice. For one resident with a PRN oxygen order due to COPD and other chronic conditions, there was no oxygen concentrator machine set up in the room, despite the order requiring oxygen to be available as needed. Both the CNA and RN Supervisor confirmed the absence of the equipment, and the DON stated that all residents with continuous or PRN oxygen orders should have a concentrator set up and a cautionary sign posted outside the room, as per facility policy. Another resident, with a history of pneumonia and asthma, had a physician's order for PRN oxygen therapy. During observation, the resident's nasal cannula tubing was found hanging on the oxygen concentrator with the prongs touching the handle, rather than being stored in a plastic bag when not in use. Both the RN and DON confirmed that the tubing should be stored in a bag for infection control, in accordance with the facility's policy and procedure for oxygen administration. A third resident, diagnosed with COPD and anemia, was observed receiving oxygen at 2.5 liters per minute via nasal cannula. However, there was no physician's order for this oxygen administration, and no sign was posted outside the resident's door to indicate oxygen was in use or to prohibit smoking. The RN confirmed the absence of a physician's order and signage, both of which are required by the facility's policy to ensure safe and accurate oxygen therapy.