Failure to Provide Correct Oxygen Flow Rate and Maintain Humidifier Water
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and acute bronchitis by not ensuring the correct oxygen flow rate and failing to maintain water in the humidifier bottle while the resident was receiving oxygen therapy. Multiple observations revealed that the resident's oxygen concentrator was consistently set to 1.5 liters, which did not align with the physician's order of 2-4 liters as needed, and the humidifier bottle was empty during each observation. The resident reported discomfort and dryness in the nostrils, which was corroborated by staff interviews acknowledging the importance of water in the humidifier to prevent dryness and potential nosebleeds. Review of the resident's care plan, physician's order, and Kardex all indicated the need for oxygen at 2-4 liters via nasal cannula as needed, with the use of a humidifier bottle. Staff interviews confirmed that the oxygen flow rate and humidifier water level should be checked and maintained according to the physician's order and facility policy. Despite these requirements, the resident was repeatedly observed either not receiving oxygen when indicated or receiving it at an incorrect flow rate with an empty humidifier bottle.