Failure to Provide Safe and Appropriate Respiratory Care with Oxygen Humidification
Penalty
Summary
A deficiency occurred when a resident with respiratory failure, hypoxia, pneumonia, COPD, and heart failure did not receive appropriate respiratory care as required by professional standards and the resident's care plan. The resident was ordered to receive oxygen therapy at 2 liters per minute via nasal cannula, with humidification and weekly changes of oxygen tubing and water for infection control. Documentation indicated that staff signed off on changing the tubing and water, but on observation, the water bottle attached to the oxygen concentrator was found empty and dated from ten days prior, while the resident was still receiving oxygen. Interviews with nursing staff revealed that they were expected to monitor oxygen settings, tubing, and water levels each shift, and to document these checks. However, staff did not notice the water bottle was empty or that the date was outdated. Some staff believed that changing the water was part of the tubing change task, and that documentation of tubing change included water change, but there was inconsistency in actual practice and awareness. Staff also reported that the water was supposed to be changed weekly, but if it emptied sooner, it could be changed as needed, which did not occur in this instance. The facility's policy required humidifiers to be checked and changed per manufacturer recommendations, and for nurses to monitor and record the resident's response to oxygen therapy. Despite these policies, the lack of water in the humidifier while the resident was receiving oxygen was not identified or addressed by staff, resulting in a failure to provide safe and appropriate respiratory care as ordered and per professional standards.