Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents by not adhering to established protocols for oxygen therapy and equipment management. For one resident with chronic heart failure and end stage renal disease, the nasal cannula used for oxygen therapy was not labeled with the date it was changed, despite physician orders and facility policy requiring weekly changes and labeling. Interviews with nursing staff and the DON confirmed that the absence of labeling could result in the use of contaminated equipment, increasing the risk of infection. Another resident, who was dependent on staff for all activities of daily living and required continuous oxygen therapy due to respiratory conditions, did not have an 'Oxygen in Use' sign posted in or outside the room. Facility policy and staff interviews indicated that this sign is necessary to alert staff and visitors to the presence of oxygen, which is a combustible gas, and to prevent potential hazards such as fire or explosion. Additionally, two residents receiving continuous or high-concentration oxygen therapy had humidifiers attached to their oxygen equipment that were not labeled with the date of last change. Both the facility's policy and physician orders required that all oxygen tubing and components, including humidifiers, be labeled and changed weekly. Staff interviews confirmed that the lack of labeling could result in the use of expired or unclean equipment, posing a risk of infection.