Failure to Provide Safe and Documented Respiratory Care for Oxygen-Dependent Resident
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident requiring continuous oxygen therapy. The resident, who had a history of heart failure, hypertension, anxiety disorder, obstructive sleep apnea, and pulmonary hypertension, was observed using oxygen at 3 liters per minute via nasal cannula. Multiple observations revealed that the oxygen tubing in use was undated, and there were no documented orders or instructions for changing the oxygen tubing in the resident's Medication Administration Record or Treatment Administration Record. Staff interviews confirmed that oxygen tubing was supposed to be changed weekly, but there was no formal policy in place, and the process was not documented or audited. Further review with the Director of Nursing and the Administrator revealed that the facility did not have a written policy for oxygen tubing changes and relied on manufacturer recommendations, which were inconsistently applied. The lack of documentation and absence of a formal order for tubing replacement contributed to the deficiency, as there was no reliable method to ensure that oxygen tubing was being changed according to professional standards or facility expectations.