Failure to Ensure Proper Oxygen Equipment Maintenance and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with COPD, as evidenced by several deficiencies in oxygen administration. Observation revealed that the resident's humidifier was completely empty, and both the nasal cannula and humidifier had not been replaced according to the facility's stated weekly schedule. Documentation review showed that there were no orders or care plan interventions specifying the regular replacement of the nasal cannula or humidifier. Interviews with nursing staff and administration confirmed that the expectation was for these items to be changed weekly, but this was not consistently documented or carried out. The resident, who had severe cognitive impairment and required continuous oxygen therapy, was unaware of the status of his humidifier and could not recall when it was last changed. Staff interviews indicated that the responsibility for changing the equipment was shared among nurses, but there was a lack of clear documentation and adherence to the schedule. Additionally, the facility's policies did not include specific requirements for oxygen administration, and no additional policy could be provided upon request. These findings were based on direct observation, staff interviews, and review of the resident's medical records and facility policies.