Inadequate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for three residents, as evidenced by discrepancies between physician orders and the actual administration of oxygen. One resident, diagnosed with acute respiratory failure with hypoxia and a malignant neoplasm of the upper lobe of the left lung, was observed receiving oxygen at 4 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Director of Nursing at the time of observation. Another resident, dependent on supplemental oxygen, was ordered to receive oxygen at 2 liters per minute but was observed receiving 3 liters per minute. Additionally, a third resident with chronic obstructive pulmonary disease was ordered to receive 3 liters of continuous supplemental oxygen but was observed using 4 liters, and the oxygen concentrator was found to be covered in dust. These findings were confirmed by the respective staff members present during the observations.
Plan Of Correction
Step 1 Resident R31, R88, R163 oxygen settings updated as per Physician orders. Step 2 All residents with Physician orders for oxygen audited to ensure oxygen concentrators are set appropriately. All oxygen concentrators audited to ensure they are free from dust/debris. Step 3 Nursing staff educated to ensure appropriate respiratory care and services provided as per physician orders. Housekeeping staff educated on the requirement to ensure oxygen concentrators are free of dust/debris. Step 4 Managers/ designee will conduct audits weekly x4, monthly x 2 to per facility protocol. Findings will be reviewed during QAPI meeting.