Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide specialized respiratory care in accordance with professional standards for two residents. For one resident, a nasal cannula used for oxygen therapy was repeatedly observed left unbagged and exposed to air on top of an oxygen concentrator, despite the resident stating it was only used at night. Both the Director of Nursing and the Infection Preventionist confirmed that unused nasal cannulas should be stored in a plastic bag to prevent contamination, but the facility's policy did not specify storage procedures for oxygen tubing when not in use. Additionally, another resident was observed using a nasal cannula for oxygen therapy without a corresponding physician's order in the electronic medical record. Interviews with nursing staff and the DON confirmed that a physician's order is required for oxygen administration, including details such as the reason, duration, dosage, and delivery method. The facility's policy also required verification of a physician's order prior to oxygen administration, but this was not followed for the resident in question.