Failure to Provide Proper Oxygen Humidification and Tubing Changes
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy. Observations revealed that the resident, who had diagnoses including COPD and chronic respiratory failure with hypoxia, was receiving oxygen via nasal cannula with an empty humidification bottle attached to the concentrator. The oxygen tubing in use was labeled with a date indicating it had not been changed in over three weeks. The resident reported experiencing a sore and dry nose, which coincided with the lack of humidification. Multiple observations confirmed the absence of humidification solution in the bottle over consecutive days. Interviews with staff, including an LPN and the DON, indicated that facility policy required weekly changes of oxygen tubing and regular monitoring and refilling of the humidification solution. The facility's own policies specified that humidification is required for oxygen flow rates of 4 liters and that the humidifier bottle should be changed when empty. Despite these policies, the resident's oxygen equipment was not maintained as required, resulting in discomfort and unmet care needs.