Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents receiving oxygen therapy. One resident with a tracheostomy and multiple respiratory diagnoses, including acute and chronic respiratory failure, was observed receiving oxygen via tracheostomy mask at 4 liters per minute with a humidification bottle that was empty on two separate occasions. Physician orders specified the use of humidified oxygen and regular changing of the humidification bottle, but these were not followed. Staff interviews confirmed that the humidification bottle should not have been empty and that staff are responsible for ensuring proper oxygen delivery and humidification. Another resident with chronic obstructive pulmonary disease (COPD) and other comorbidities was observed receiving oxygen at 4 liters per minute via nasal cannula, while the physician order specified oxygen at 2 liters per minute as needed for shortness of breath. The oxygen concentrator was also not within the resident's reach during observations. Staff confirmed the discrepancy between the ordered and administered oxygen flow rate and were unaware of how the error occurred. Facility policy required staff to review physician orders and ensure the correct oxygen flow, but this was not adhered to in these cases.