Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents requiring oxygen therapy. For one resident with COPD and respiratory failure, the nasal cannula was connected to a humidifier bottle that was not properly attached, resulting in no oxygen being delivered. This was confirmed by the absence of bubbles in the humidifier bottle, and the issue was only corrected after multiple attempts by an LPN. The resident had a physician's order for continuous oxygen at 3 liters per minute, and facility policy required that the humidifier bottle be securely fastened and bubbling to ensure oxygen delivery. Another resident with chronic respiratory conditions was observed receiving oxygen via nasal cannula at 2 liters per minute, but the oxygen tubing was not labeled with the date it was last changed. Facility policy and the resident's order required weekly changes of oxygen tubing, with labeling and dating to ensure proper infection control. The resident was unable to be interviewed due to severely impaired cognition, and the Assistant Director of Nursing confirmed the expectation for weekly tubing changes and proper labeling. A third resident with multiple respiratory and cardiac diagnoses was observed receiving oxygen at a flow rate of 4 liters per minute, despite an active physician's order for 3 liters per minute continuously. The LPN on duty verified the discrepancy and acknowledged the need to follow the physician's order to prevent complications. The ADON stated that nurses are responsible for ensuring oxygen is set according to orders during medication passes and pulse oximetry checks.