Failure to Ensure Continuous Oxygen Supply and Proper PPE Use
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required supplemental oxygen. In both cases, the residents' portable oxygen tanks were found to be empty during routine activities, despite physician orders for continuous oxygen therapy. One resident, who had diagnoses including COPD and chronic respiratory failure with hypoxia, was observed calling for assistance when she noticed her oxygen was not flowing, and staff confirmed her tank was empty. The care plan for this resident did not specify how often staff should check the oxygen tank to ensure it remained full. Another resident, with a history of COPD and other chronic conditions, was also found with an empty portable oxygen tank. Staff noted that the tank had been refilled earlier but suspected a malfunction due to abnormal behavior of the tank's dial, which may have contributed to the tank being empty prematurely. Additionally, the facility did not ensure that staff used the appropriate personal protective equipment (PPE) when filling portable oxygen tanks, as required by facility policy. The deficiency was identified through observations, record reviews, and staff interviews, which revealed lapses in monitoring oxygen tank levels and adherence to safety protocols for handling respiratory equipment. These failures resulted in residents not receiving oxygen as ordered and not being protected during the refilling process.