Failure to Provide Proper Respiratory Care and Maintain Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy. The resident, who was cognitively intact and had diagnoses including anxiety disorder, hypertension, and unsteadiness, was observed using a nasal cannula for oxygen. However, there were no physician orders for oxygen therapy or related care in the resident's records at the time of review. The resident's care plan did not include any respiratory treatment, and the MDS assessment did not indicate oxygen therapy. Orders for oxygen therapy were only added after the issue was identified during an interview with a nurse. Additionally, the resident's oxygen humidifier was found to be empty during multiple observations, and the resident reported that staff often forgot to check or change it, requiring her to remind them. The humidifier bottle had not been replaced in a timely manner, and staff interviews confirmed that the humidifier was changed weekly or as needed, but in this case, it had not been addressed despite being empty. The facility's policy required respiratory equipment to be maintained per manufacturer's instructions or physician's orders, but this was not followed for the resident in question.