Failure to Provide Adequate Respiratory Care Leads to Resident's Death
Summary
The facility failed to provide necessary respiratory care and implement interventions for a resident diagnosed with chronic obstructive pulmonary disease (COPD) exacerbation and a history of pneumonia. The resident experienced severe respiratory distress, with oxygen saturation dropping to 72% while receiving oxygen via nasal cannula at 2 liters per minute. Despite the resident's condition, the facility did not monitor and evaluate the effectiveness of the oxygen provided, nor did they follow physician orders to adjust the oxygen therapy to maintain oxygen blood levels at 92%. The Licensed Vocational Nurse (LVN) on duty did not document the resident's respiratory distress or report the change in condition to the physician, as required by the facility's policy and procedure. The LVN also failed to notify emergency services immediately when the resident exhibited signs of respiratory distress and refused to go to the hospital. The resident's refusal to be transferred to the hospital was not communicated to the physician, and no alternative interventions were discussed or documented. As a result of these deficiencies, the resident did not receive immediate respiratory care and interventions, leading to their death after unsuccessful CPR was administered. The California Department of Public Health identified an Immediate Jeopardy situation due to the facility's failure to notify the physician and provide necessary respiratory care and monitoring for the resident.
Removal Plan
- The Director of Nursing (DON) conducted a full house audit to identify all residents with a diagnosis of COPD, those on continuous and PRN oxygen. The audit identified 10 residents with COPD and 18 residents receiving oxygen therapy. The DON reviewed the care plans and physician's orders for these residents to ensure appropriate interventions such as following MD orders, oxygen therapy orders, repositioning of patients, checking oxygen saturation, assessment of signs and symptoms of hypoxia respiratory failure for effectiveness of the intervention and monitoring for signs and symptoms of respiratory distress, verifying respiratory status using objective data such as oxygen saturation were in place. The DON will also review the communication to the Primary Care MD, if no response, the medical director and or emergency services will be called immediately. No additional residents were found to be at immediate risk.
- A one to one in-service regarding MD notification, Medical Director notification, and emergency services was provided to the Night Shift Licensed Nurse assigned to Resident 77 by the facility's DON. The Licensed Nurse was also suspended pending the facility's investigation.
- The Pharmacy Consultant initiated Medication Regimen Reviews for all residents receiving Oxygen Therapy and with COPD/SOB.
- The facility conducted a root cause analysis (RCA) which included interviews with involved staff. The RCA revealed the following contributing factors: Lack of staff education on monitoring and reporting changes in respiratory status, and inadequate communication between nursing staff and physicians regarding significant changes in condition.
- The Certified Nursing Assistant (CNA) assigned to Resident 77 during the night shift was provided a one-to-one in-service regarding Emergency Care Policy and Procedure.
- The Director of Nursing/ Staff Development Coordinator (DSD) started to provide in-services to all Licensed Nursing staff for all shifts including CNAs, LVNS, RNs on Emergency Medical Response: A. Monitoring and reporting changes in respiratory status B. Following physician orders for oxygen titration and maintaining target oxygen saturation levels, and C. Facility policy and procedure for responding to respiratory distress, including immediate notification of the primary physician, emergency services, and medical director.
- The DON reviewed the facility's policy and procedure for responding to respiratory distress to ensure clarity and consistency with current standards of practice.
- The DON created a monitoring tool related to COPD and Oxygen Therapy to ensure clarity and consistency with current standards of practice.
Penalty
Resources
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Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with chronic respiratory failure with hypoxia and CHF had a physician order for oxygen at 0–2 LPM via nasal cannula as needed to maintain SpO2 ≥ 88%, with pulse oximetry checks each shift. Documentation showed SpO2 readings of 90–95% and that the resident was occasionally given 3 LPM of oxygen. Surveyors observed the resident with an oxygen concentrator running at 2.5 LPM while not wearing the nasal cannula, and later with oxygen in use while the concentrator was set at 3 LPM. The DON reviewed the record and confirmed the order was for 0–2 LPM and that the concentrator should have been set within that range, demonstrating that oxygen therapy was not consistently provided per the physician’s order.
Surveyors found that three residents receiving continuous O2 therapy did not receive care consistent with facility policy and MD orders. One resident with COPD and another with heart failure were observed on concentrators whose humidifier bottles or external filters were dusty and covered with fuzz-like debris, and required weekly cleaning and tubing changes were not evident. A third resident on 2 L O2 had undated oxygen tubing, and the clinical record lacked documentation that tubing was changed as ordered. Staff, including the RT and DON, confirmed that appropriate respiratory care and oxygen equipment maintenance were not provided.
The facility failed to follow physician orders and manufacturer instructions for oxygen and PAP therapy for three residents. One resident with COPD and cardiomegaly had an order for continuous O2 at 3 LPM via nasal cannula but was repeatedly observed without the cannula in place. Another resident with PTSD and obstructive sleep apnea had orders for CPAP with supplemental O2 at HS and O2 every shift, yet was observed not using O2 during the day, and oxygen was allowed to bleed into a CPAP device that was turned off without the required pressure valve installed. A third resident with osteomyelitis and a lumbar fracture had an order and care plan for continuous 2 LPM O2 to maintain SpO2 ≥ 90%, but was observed off oxygen and had documented SpO2 readings of 88% on room air. The CNO acknowledged staff had not ensured ordered oxygen use and was unaware of the required pressure valve for PAP devices.
A resident with a tracheostomy and acute respiratory failure with hypoxia had physician orders and a care plan for routine trach care, including changing or cleaning the inner cannula as applicable. On two night shifts, an RN provided trach care and later reported that on one of those shifts there were no extra single-use disposable inner cannulas in the resident’s room. Instead of obtaining a new cannula from other supplies, the RN used a trach care kit with sterile gloves, sterile water, and a sterile brush to clean the disposable inner cannula and reinserted it, despite knowing it was labeled for single use and acknowledging that reuse could pose an infection risk. The DON and Administrator later confirmed that only single-use disposable inner cannulas are used and that they are not to be cleaned and reused.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy according to physician orders for a resident receiving respiratory care. Facility policy required that oxygen be administered under a physician’s order except in an emergency. The resident was admitted with chronic respiratory failure with hypoxia and congestive heart failure, and the care plan documented that the resident used oxygen per physician order. A physician order dated 3/26/26 specified oxygen at 0–2 LPM via nasal cannula as needed to maintain oxygen saturation at or above 88%, with oxygen saturation checks every shift. The March and April 2026 MAR/TAR showed oxygen saturations ranging from 90–95% and documented that the resident was occasionally receiving 3 LPM of oxygen as needed. On 3/30/26 at 1:00 PM, the resident was observed in bed with the head of the bed elevated, the oxygen concentrator running and set at 2.5 LPM, but the resident was not wearing the nasal cannula and stated he used oxygen at night and when napping. On 4/3/26 at 9:26 AM, the resident was observed lying in bed with oxygen on via nasal cannula, and at 10:43 AM the same day, the DON observed the resident still in bed with oxygen via nasal cannula and identified the concentrator setting as 3 LPM. When the DON reviewed the record at 10:45 AM, she confirmed the physician order was for 0–2 LPM via nasal cannula and acknowledged that the concentrator should have been set between 0–2 LPM, indicating that the resident had been receiving oxygen at a flow rate above the ordered range.
Failure to Maintain Oxygen Equipment and Provide Ordered Respiratory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory care and maintain oxygen equipment in accordance with its own policy and physician orders for three residents receiving oxygen therapy. Facility policy dated 8/15/25 required that all residents on oxygen have tubing, masks, and cannulas changed weekly and concentrator external filters cleaned weekly. For one resident with COPD, muscle wasting, and abnormal lung findings, a physician order dated 1/12/26 directed weekly cleaning of the oxygen concentrator and filter and weekly tubing changes. On observation, this resident was in the main dining room on oxygen via nasal cannula with an oxygen concentrator whose humidifier bottle was empty and still labeled with a date from earlier in the month, and the concentrator and external filter were dusty with a layer of fuzz-like debris. The respiratory therapist confirmed these observations. Another resident, admitted with constipation, hypertension, and pneumonia, had a care plan directing oxygen at 2 L with oxygen precautions and a physician order for continuous 2 L oxygen and tubing changes every seven days. During observation, this resident’s oxygen tubing was not dated, and review of the clinical record showed no evidence that the tubing was changed as ordered. A third resident with heart failure, hypertension, and depression had a physician order identical to the first resident’s, requiring weekly cleaning of the concentrator and filter and weekly tubing changes. Observation showed this resident sitting in a wheelchair connected to a concentrator by nasal cannula with undated tubing and a concentrator and external filter that were dusty with a layer of fuzz-like debris. The respiratory therapist and the DON confirmed that appropriate respiratory care and oxygen equipment maintenance were not provided for these three residents.
Failure to Provide Ordered Oxygen and Safe PAP Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services as ordered for three residents requiring continuous or prescribed oxygen and PAP therapy. Facility policy required BiPAP/CPAP therapy to be provided in accordance with physician orders and professional standards, and the PAP user manual specified that when oxygen is used with the device, a specific pressure valve must be installed between the device and oxygen source, and that the device must be turned on before oxygen and off after oxygen is turned off to prevent oxygen accumulation and fire risk. For one resident with COPD, depression, and cardiomegaly, a physician order dated 3/9/26 required oxygen at 3 LPM continuously via nasal cannula, yet surveyors observed on three separate dates and times that the resident was in her room without the nasal cannula in place. The CNO confirmed that this resident should have had her oxygen on continuously as ordered and had not. Another resident with PTSD and joint replacement aftercare had CPAP orders specifying CPAP with 2 L/min oxygen at bedtime and a separate physician order for oxygen at 3 L via nasal cannula every shift for obstructive sleep apnea. On observation with an RN present, the resident’s oxygen concentrator was on and bleeding 3.5 LPM of oxygen into the CPAP device while the CPAP device itself was turned off, and no required Respironics pressure valve was installed in the PAP circuit. Additional observations on two mornings showed the resident was not using ordered oxygen, and an RN stated the resident does not use oxygen during the day and questioned whether there was an order for daytime use. A third resident with acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture had a physician order and care plan for 2 LPM oxygen continuously via nasal cannula to maintain SpO2 at or above 90%, yet was observed not using oxygen, and medical record entries documented SpO2 readings of 88% on two dates while on room air only. The CNO stated staff should have ensured ordered oxygen use for the two residents, acknowledged oxygen should not bleed into a PAP device when not in use, and reported being unaware of the requirement for the Respironics pressure valve or whether any PAP devices in the facility had it.
Improper Reuse of Single-Use Tracheostomy Inner Cannula
Penalty
Summary
The deficiency involves the facility’s failure to provide tracheostomy care consistent with professional standards of practice when a nurse cleaned and reused a single-use disposable tracheostomy inner cannula for a resident. The resident had been admitted with acute respiratory failure with hypoxia and had a physician’s order for tracheostomy care every shift and as needed, including cleaning or changing the inner cannula as applicable. The resident’s care plan identified a risk of complications related to the tracheostomy, with an intervention for tracheostomy care as ordered. Documentation on the Treatment Administration Record and nursing progress notes showed that the same nurse provided tracheostomy care on two consecutive night shifts, during which the care was documented as well tolerated. In a later interview, the nurse stated that the resident’s tracheostomy inner cannulas were always single-use disposable types and that during one of those night shifts there were no extra inner cannulas in the resident’s room. She reported that, needing to provide tracheostomy care, she used a tracheostomy care kit with sterile gloves, sterile water, and a sterile brush to clean the disposable inner cannula and then reinserted it instead of discarding it and using a new one, acknowledging she knew this was not permitted and that reusing a disposable inner cannula could risk infection. She also stated she did not look for additional cannulas outside the resident’s room and did not have access to the supply room. The DON and Administrator later confirmed they were unaware of the incident at the time and affirmed that the facility used only disposable inner cannulas intended for single use and that they should not be cleaned and reused.
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