Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for Resident R17, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, and respiratory failure. The resident required the use of a BIPAP machine at night, as indicated in the hospital discharge summary. However, the facility did not enter a physician order for the BIPAP settings upon admission, and the resident's BIPAP machine was reportedly broken and not used for several nights. This lack of proper documentation and equipment maintenance contributed to the resident's respiratory distress and subsequent hospitalizations. Observations and interviews revealed that the resident's BIPAP mask was not stored properly and was visibly dirty, with the filter being filthy with lint. The resident expressed that he had never refused the BIPAP and was aware of its necessity. Despite this, the facility did not ensure the BIPAP equipment was clean and functional, nor did they follow the manufacturer's guidelines for maintenance and replacement of parts. Additionally, the resident was observed receiving incorrect oxygen therapy, with discrepancies in the prescribed and administered oxygen levels. The facility also failed to schedule a follow-up pulmonary appointment as ordered, further neglecting the resident's respiratory care needs. Interviews with staff confirmed the absence of necessary orders and the improper handling of the BIPAP equipment. The Nursing Home Administrator acknowledged the facility's failure to provide appropriate respiratory care, which was evident in the repeated hospitalizations of the resident due to respiratory distress.
Plan Of Correction
R17's BIPAP was immediately cleaned, and filter was changed. Resident education also provided. Observation of all respiratory equipment completed to ensure proper cleaning, dating and storage use. Like residents' machines were visually assessed and changes made as needed. Education was immediately provided to nursing staff and will be completed on the importance of regular maintenance and correct usage by DON or designee on or before 2/11/2025. This education includes proper cleaning, dating, and storage of equipment. Audits will be completed on proper storage, cleanliness, orders, care plans, dating and storage by DON or designee 3 times weekly for 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.