Deficiencies in Respiratory Care for Residents
Summary
The facility failed to ensure that a resident, who required oxygen therapy, had a physician's order for its administration. Resident #49, a female with chronic obstructive pulmonary disease (COPD), was observed using an oxygen concentrator set at 2 liters per minute without a corresponding physician's order. Despite the presence of an order to change the oxygen tubing weekly, there was no documented order for the actual administration of oxygen. Interviews with the LPN and DON confirmed the absence of an order and highlighted the necessity of having a physician's order for oxygen therapy, as it is considered a medication. Another deficiency was identified with Resident #77, who used a BiPAP machine for sleep apnea. The BiPAP mask was observed on the resident's side table without being properly stored in a plastic bag, which is necessary to prevent cross-contamination and infection. The resident was not informed about the need to bag the mask, and staff failed to notice and address the improper storage during their rounds. Interviews with RN B and the ADON revealed that the staff did not consistently ensure the BiPAP mask was bagged when not in use, and there was a lack of education provided to the resident regarding proper storage. The facility's policies on oxygen administration and noninvasive ventilation require a physician's order for oxygen therapy and proper storage of BiPAP masks, respectively. However, these policies were not adhered to, resulting in the deficiencies observed. The lack of a physician's order for oxygen therapy and the improper storage of the BiPAP mask could potentially place residents at risk for respiratory infections and unmet respiratory needs.
Penalty
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Staff failed to follow oxygen safety and administration requirements for two residents on oxygen therapy. One resident receiving O2 at 2 L/min for shortness of breath had no “Oxygen in Use” signage posted at the doorway or in the room, despite facility policy requiring such signs due to oxygen being a fire hazard. Another resident with COPD and an order for O2 at 2 L/min was observed twice with the concentrator flow meter set above the ordered rate, and the concentrator was not within the resident’s reach. An LPN acknowledged that nurses should verify the physician’s order and ensure the flow meter ball is centered on the prescribed liter line, consistent with the manufacturer’s instructions and facility policy.
A resident with a history of acute respiratory failure, CHF, and OSA was not provided with CPAP therapy as ordered in the hospital discharge summary. Although staff communicated with a NP and a respiratory therapist about setting up a device, there was no documentation that CPAP was initiated during the resident's stay. Staff interviews confirmed that the facility is responsible for providing a CPAP if the resident cannot bring their own, but this was not done.
Facility staff did not obtain a physician's order for an incentive spirometer for a resident and failed to store the device in a sanitary manner, leaving the mouthpiece uncovered on the nightstand. An LPN confirmed that orders and proper storage are required, but no policy was provided by the facility.
Staff did not provide a resident with continuous oxygen therapy as ordered by the physician, and failed to label or date the oxygen tubing and humidifier bottle. The oxygen equipment was present but not in use, and documentation inaccurately reflected that therapy had been administered. Facility policy requiring proper administration and labeling was not followed.
A resident with respiratory failure was observed receiving oxygen via nasal cannula without a physician's order in place at the time of administration. The order for continuous oxygen was documented only after the resident had already begun receiving therapy, as confirmed by the unit manager.
A resident with multiple chronic conditions and moderate cognitive impairment was observed on several occasions to have their CPAP machine, tubing, and mask left uncovered and open to air on the bedside table when not in use, contrary to facility policy requiring storage in a plastic bag. Staff did not follow established infection control procedures for respiratory equipment.
Failure to Follow Oxygen Safety Signage and Prescribed Flow Rates
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for two residents receiving oxygen therapy. For one resident with a physician’s order for oxygen at two liters per minute for shortness of breath, surveyors twice observed the resident in bed on oxygen via nasal cannula and concentrator without any cautionary or safety signage indicating oxygen use at the doorway or in the room. An LPN stated that when a resident is receiving oxygen, a sign is supposed to be posted outside the room door to alert staff that the resident requires oxygen and because oxygen is flammable. Facility policy on oxygen administration documented that oxygen is considered a fire hazard and that “Oxygen in Use” signage should be posted where applicable. For another resident with a physician’s order for oxygen at two liters per minute for chronic obstructive pulmonary disease, surveyors observed the oxygen concentrator flow meter set above the ordered rate on two occasions. The first observation showed the ball in the flow meter between the three- and four-liter lines, and the second observation showed the ball between the two- and three-liter lines, while the concentrator was not within the resident’s reach during either observation. The LPN interviewed stated that nurses should check the physician’s order and verify the correct oxygen amount by viewing the flow meter at eye level and ensuring the middle of the ball runs through the prescribed line. The manufacturer’s instructions for the concentrator specified that the flow should be adjusted until the ball is centered on the line marking the specific flow rate, and the facility’s oxygen administration policy required verification of the physician’s order prior to initiation and application of the prescribed flow rate.
Failure to Provide Required CPAP Therapy for Resident with Sleep Apnea and CHF
Penalty
Summary
Facility staff failed to provide necessary respiratory care for a resident who required CPAP therapy following a hospital stay for acute respiratory failure secondary to congestive heart failure and obstructive sleep apnea. The hospital discharge summary specified the need for CPAP at night, but a review of the resident's clinical record showed no evidence that CPAP therapy was initiated during the resident's stay. Progress notes indicated that staff communicated with a nurse practitioner regarding the placement of a BiPAP device, and a respiratory therapist was notified to set up the machine, but there was no documentation that the CPAP was ever provided. Interviews with staff revealed that the admitting nurse is responsible for verifying CPAP orders with the physician and informing them if the facility does not have a CPAP machine available. Staff also stated that it is the facility's responsibility to provide a CPAP device if the resident is unable to bring their own from home. Despite these procedures, the facility did not provide the required CPAP therapy, and no policy or additional information regarding CPAP provision was supplied when requested by surveyors.
Failure to Obtain Physician Order and Maintain Sanitary Storage for Incentive Spirometer
Penalty
Summary
Facility staff failed to provide appropriate respiratory care and services for one resident by not obtaining a physician's order for the use of an incentive spirometer. The resident's clinical record did not contain an order for the device, and the admission minimum data set assessment was incomplete. The resident was alert and oriented at the time of admission, and a clinical admission assessment was documented, but there was no documentation supporting the use of the incentive spirometer as ordered by a physician. During observation, the incentive spirometer was found on the resident's nightstand with the mouthpiece uncovered, and the resident confirmed using the device without staff providing a cover. An LPN interviewed stated that a physician's order is required for incentive spirometer use, including frequency, and that the device should be stored in a plastic bag for infection control. The facility did not provide a policy regarding incentive spirometer use, and no further information was presented before the survey exit.
Failure to Administer Ordered Oxygen Therapy and Label Equipment
Penalty
Summary
Facility staff failed to administer oxygen therapy as ordered by the physician for one resident. Observations revealed that the resident was not receiving continuous oxygen via nasal cannula at two liters, as prescribed. The oxygen concentrator was present in the resident's room, but the humidifier bottle was found on the floor and there was no oxygen tubing connected to the concentrator. The resident's spouse confirmed that the oxygen had not been in use since the previous day, and that the tubing had been removed from the room. Multiple observations throughout the day confirmed that the resident was not receiving oxygen as ordered, and staff had not checked on the resident's oxygen levels during this period. Further review showed that the oxygen tubing and humidifier bottle were not labeled or dated, as required. The clinical record indicated that the oxygen order had been signed off as administered, despite the resident not receiving it. The care plan also reflected the need for continuous oxygen at two liters via nasal cannula. Facility policy required licensed clinicians to administer oxygen as ordered, but this was not followed in this instance. The deficiency was brought to the attention of facility leadership during an end-of-day meeting.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
Facility staff failed to provide appropriate respiratory care for one resident by not obtaining a physician's order for oxygen therapy prior to administration. The resident was admitted with diagnoses including respiratory failure and was assessed as cognitively intact. During an observation, the resident was found to be receiving oxygen at three liters per minute via nasal cannula. At the time of the observation, there was no documented physician's order for the oxygen therapy being administered. The physician's order for continuous oxygen at three liters per minute by nasal cannula was only created later that same day, after the resident had already been observed receiving oxygen. This lapse was confirmed by the unit manager, who acknowledged that no order was present at the time of the surveyor's observation.
Failure to Properly Store CPAP Equipment According to Infection Control Policy
Penalty
Summary
Facility staff failed to provide respiratory care according to professional standards of practice for a resident who required CPAP therapy. Multiple observations over three consecutive days revealed that the CPAP machine, including its tubing and mask, was left uncovered and open to air on the resident's bedside table when not in use. This was in direct contradiction to the facility's own policy, which required that CPAP and BiPAP masks be stored within a plastic bag when not in use, with the bag changed weekly or as needed. The resident involved had a complex medical history, including aphasia following cerebral infarction, chronic kidney disease stage two, type two diabetes, Barrett's esophagus, nontraumatic subarachnoid hemorrhage, a history of cerebral infarction, and coronary atherosclerosis due to lipid plaque. The resident was assessed as having moderate cognitive impairment and required assistance with all activities of daily living, using a wheelchair for mobility. Despite physician orders for nightly CPAP use, staff did not follow infection control protocols for storing the equipment, as documented in the facility's policy.
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