Failure to Provide Ordered Oxygen Therapy and Maintain Sanitary Equipment
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician and did not maintain the oxygen tubing and humidifier bottle in a sanitary manner for a resident with multiple medical conditions, including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder. The resident's care plan required oxygen administration as ordered, and the physician's order specified oxygen at 3 liters per nasal cannula every shift, with tubing and humidity to be changed weekly and dated. During observation and interview, the resident's oxygen tubing and humidifier bottle were found lying on the floor without dates, and the resident reported waiting for an hour for new supplies. The resident also stated that the oxygen concentrator had been broken for a long time and that the humidifier bottle was always placed on the floor. Staff interviews confirmed that the nurse was responsible for maintaining the resident's oxygen equipment, but the required care had not been provided. The Assistant Director of Nursing Services (ADNS) responded by bringing new, dated supplies and attempted to address the broken concentrator. The resident's oxygen saturation was measured at 92-94% without oxygen and increased to 99% when oxygen was provided. The Director of Nursing Services (DNS) stated that staff were expected to ensure residents received oxygen as ordered and that equipment should be dated, confirming that facility expectations were not met in this instance.