Failure to Follow Oxygen Therapy Orders and Maintain Equipment Cleanliness
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident with COPD and shortness of breath. The resident was observed multiple times over several days lying in bed with an oxygen nasal cannula, and the oxygen concentrator was consistently set to 4 liters per minute. However, the physician's order specified oxygen at 0-2 liters per minute via nasal cannula as needed for shortness of breath or low oxygen saturation. The care plan also directed staff to provide oxygen therapy as needed to maintain appropriate oxygen saturation levels. Despite these orders, the resident received oxygen at a higher rate than prescribed. Additionally, the oxygen concentrator's filter was repeatedly observed to be filled with dust during these observations. Nursing staff interviews revealed that oxygen levels were not checked as frequently as required, and staff were unaware of the dirty filter. The DON confirmed that oxygen orders should be followed as prescribed and that concentrators are expected to be clean, with responsibility for cleaning assigned to nursing or housekeeping staff.