Deficiencies in Respiratory Equipment Care for Two Residents
Penalty
Summary
The facility failed to maintain proper respiratory care for two residents, leading to deficiencies in care. Resident R27, who was admitted with conditions including obstructive sleep apnea and respiratory failure, did not have a physician's order or care plan for the use of a CPAP machine, which was brought from home. Despite abnormal lab results and a fall that resulted in low oxygen saturation levels, the CPAP machine was not properly utilized or maintained. Observations revealed the CPAP mask and tubing were left on the floor, and the machine was not connected to the oxygen concentrator, indicating a lack of proper equipment management and care. Resident R50, who had diagnoses including chronic obstructive pulmonary disease and dependence on supplemental oxygen, had a physician's order to clean the oxygen concentrator filter and change tubing weekly. However, observations showed that the oxygen concentrator filter was covered in a thick layer of greyish white, fluffy substance, indicating that the equipment was not cleaned as required. This lack of maintenance could potentially compromise the resident's respiratory care. Interviews with staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, confirmed the deficiencies in equipment care and management for both residents. The Nursing Home Administrator also confirmed the absence of necessary documentation and care plans for Resident R27's CPAP machine, highlighting a systemic issue in ensuring proper respiratory care and equipment maintenance in the facility.
Plan Of Correction
Resident #27 orders were updated to contain CPAP and settings, and CPAP machine is functioning. Resident #27 care plan was revised. Resident #50 oxygen concentrator filter was cleaned at time of findings. All residents with CPAPs were reviewed to ensure that they have physician orders and care plans for CPAP machines by the Director of Nursing/Designee. All oxygen concentrators were checked to ensure filters were clean and in working order by the Director of Nursing/Designee. Licensed staff to be educated on CPAP machines and obtaining orders for CPAP machines, updating the care plan, and maintenance of respiratory equipment by the Director of Nursing/Designee. An audit will be conducted by the Director of Nursing/Designee to ensure that all residents with CPAPs were reviewed to ensure that they have physician orders and care plans for CPAP machines and all oxygen concentrators were checked to ensure filters were clean and in working order. The audit will occur 3 times a week for 4 weeks, 2 times a week for 3 weeks then weekly ongoing. The audit will be monitored by the Administrator and findings will be reported to the Quality Assurance Meeting for review and recommendations.