Failure to Provide Ordered Respiratory Equipment Care for Oxygen Therapy
Penalty
Summary
Surveyors identified a deficiency in the provision of necessary respiratory care related to oxygen therapy equipment for one resident receiving oxygen via nasal cannula. On 02/09/2026, the resident was observed in bed on 2 liters of oxygen via nasal cannula with oxygen tubing that was not dated and an oxygen concentrator that did not have a humidifier attached. The resident had a physician order, dated 11/20/2025, for oxygen at 2 liters via nasal cannula as needed, but there were no accompanying physician orders specifying care of the respiratory equipment, such as tubing changes or humidifier use. During an interview, the resident reported that his/her nose becomes dry from the oxygen. On 02/10/2026, an LPN stated that a physician's order is required to change the nasal cannula, that oxygen tubing is changed every 24 hours, and that staff date the humidifier bottle, and confirmed that the resident’s oxygen tubing was undated and no humidifier was in use. The RN Unit Manager explained that oxygen therapy requires a physician’s order that includes specific instructions for respiratory equipment care, including weekly changes and dating of oxygen tubing and humidifier bottles, and stated she expected such an order to be in place. The DON similarly confirmed that physician orders are required for respiratory equipment care, including weekly or as-needed oxygen tubing changes and humidifier care, and acknowledged that such orders for this resident’s oxygen equipment had not been in place for the three months prior to surveyor intervention.
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