Failure to Ensure Safe and Ordered Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents requiring oxygen therapy. For one resident with chronic respiratory failure, COPD, and pneumonia, oxygen was administered via nasal cannula without a physician's order, and the oxygen tubing in use was not changed according to the facility's policy, as evidenced by tubing dated several weeks prior. The resident's medical record did not contain any physician's order for oxygen administration or tubing changes, contrary to facility policy requiring such orders and weekly tubing changes. For another resident, the oxygen nasal cannula was not properly in place, and the resident was observed to be out of breath and self-administered an inhaler. The oxygen concentrator's humidifying jar was found empty during one observation, and only later was it refilled. Staff interviews confirmed that nurses are responsible for checking and refilling humidifying jars, and that humidifying jars should not be empty while in use. Facility policy also requires that the humidifying jar contains enough water to bubble as oxygen flows through, which was not consistently maintained.