Failure to Properly Administer and Document Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required continuous oxygen therapy. For one resident with diagnoses including Paroxysmal Atrial Fibrillation and Chronic Respiratory Failure, staff did not ensure that oxygen tubing and humidifier bottles were dated as required by facility policy. The resident was observed sitting in a hallway without oxygen, despite a physician's order for continuous oxygen at 3 liters per minute with humidification. The oxygen tubing was found undated and lying in a wheelchair, and the humidifier bottle was also undated. Additionally, the oxygen concentrator in the resident's room was left running while the resident was not present, and undated oxygen tubing was observed on the floor. Staff confirmed the lack of dating and labeling on the equipment and acknowledged the resident's order for continuous oxygen. For another resident with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Cor Pulmonale, Chronic Congestive Heart Failure, and Pan lobular Emphysema, the facility did not date the oxygen tubing or humidifier bottle as required. The resident was observed receiving oxygen at a flow rate of 3 liters per minute, which was higher than the physician-ordered rate of 2 liters per minute. Staff confirmed both the incorrect flow rate and the absence of required dating on the oxygen equipment. These deficiencies were identified through observation, interview, and record review.