Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents who required oxygen therapy, as evidenced by multiple deviations from physician orders and facility policy. Two residents had physician orders for oxygen administration at two liters per minute, but observations revealed their oxygen concentrators were set at higher rates (three and four liters per minute, respectively). Additionally, one resident's oxygen concentrator had an empty water container, and another had no water container attached, contrary to the facility's policy requiring humidification. Both residents also had nebulizer tubing at their bedside that was not bagged when not in use, increasing the risk of contamination. Interviews with the residents indicated they were unaware of the issues with their oxygen equipment, and staff interviews confirmed the discrepancies between the orders and the care provided. Another resident, who had a diagnosis of Chronic Obstructive Pulmonary Disease and diabetes, was observed with a nasal cannula in place, but the tubing was disconnected from the concentrator and lying on the floor. When staff were notified, an LPN reconnected the tubing to the concentrator without cleaning, sanitizing, or replacing it, despite acknowledging the risk of contamination. Staff interviews confirmed that oxygen settings, tubing, and humidification should be checked every shift, and that tubing should be replaced if contaminated. The Director of Nursing stated that her expectation was for staff to follow physician orders and facility policy regarding oxygen administration.