Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Specifically, the resident did not have a current physician's order for oxygen use, and there were no orders in place for changing the oxygen tubing and water or for cleaning the filter. Observations revealed that the resident was using oxygen via nasal cannula at 2.5 L/min with undated tubing and an empty water bottle that had not been changed since a previous date. Interviews with nursing staff and the DON confirmed that the tubing and water were not changed or dated as required, and that the lack of an active order for oxygen contributed to the oversight. The facility's policy required verification of a physician's order and periodic checking of the water level but did not specify the frequency for changing tubing. The resident involved had a history of chronic obstructive pulmonary disease, emphysema, a pulmonary nodule, dementia, and high blood pressure. The care plan indicated a need for oxygen therapy per medical orders, but the most recent order had been discontinued months prior. Staff interviews acknowledged that the failure to maintain proper respiratory care practices, including changing and dating the tubing and water, and the absence of a current order, placed the resident at risk for infection and improper oxygen administration. The deficiency was identified through observation, record review, and staff interviews.