Failure to Label Respiratory Equipment and Follow Oxygen Orders
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care to a resident receiving oxygen therapy. During observation, it was found that the oxygen tubing, nasal cannula, and humidifier bottle in use for the resident were not labeled or dated as required. The LPN present was unable to state when the equipment was last changed and acknowledged that it should be changed weekly and labeled accordingly. The Director of Nursing confirmed that the facility's expectation is for equipment to be labeled and dated immediately after being changed, with changes occurring weekly. Additionally, the staff did not follow the physician's order for oxygen administration. The resident was observed receiving oxygen at approximately 2.25 liters per minute, while the active physician order specified 2 liters per minute to maintain oxygen saturation above 92%, with titration up to 6 liters per minute only as needed. The LPN confirmed there was no clinical indication for the increased flow rate and subsequently adjusted it to the prescribed amount. The most recent oxygen saturation documented for the resident was 99%.