Failure to Ensure Proper Oxygen Management and Safety Precautions
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required supplemental oxygen, as observed through multiple deficiencies in oxygen management. Specifically, the resident's nasal cannula and tubing were not stored in a protective bag or Wiki-pouch when not in use, but instead were wrapped around the oxygen tank on the resident's wheelchair. This practice was confirmed by both staff and the resident, with a CNA stating that there were no bags available for storage and acknowledging that improper storage could lead to cross-contamination. The Director of Nursing (DON) and Administrator both stated that the expectation was for the nasal cannula and tubing to be stored in a Wiki-pouch to prevent infection, in accordance with facility policy. Additionally, there was no "oxygen in use" sign posted outside the resident's room, despite the presence of both an oxygen tank and concentrator in the room. Both the DON and Administrator confirmed that such signage was required to alert staff and visitors to the presence of oxygen, which is necessary for safety and infection control. Record reviews indicated that the resident had a history of dementia and was dependent on supplemental oxygen, with care plans and physician orders specifying continuous or as-needed oxygen therapy. These failures were identified through observation, interviews, and record review, and were not in line with professional standards of practice or facility policy.