Deficiency in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents. Resident 96, who has a diagnosis of respiratory failure with hypoxia and COPD, was ordered to receive supplemental oxygen at 4 LPM via nasal cannula with humidification. However, observations revealed that the resident was receiving oxygen at only 1.5 LPM, contrary to the physician's order. This discrepancy was confirmed by a licensed practical nurse who then adjusted the oxygen flow to the correct rate. For Resident 49, there was an active physician's order to administer supplemental oxygen if the pulse oximeter reading fell below 92 percent. However, the order did not specify the oxygen flow rate, and no supplemental oxygen was observed in use. Additionally, there were no documented oxygen saturation assessments for this resident, despite the physician's order. The care plan for Resident 49 did not include an intervention for supplemental oxygen, and the intervention for oxygen was discontinued, although the physician's order remained active.
Plan Of Correction
The facility corrected the O2 settings for resident 96. The order for resident 49's supplemental oxygen was discontinued. An audit of current residents with oxygen was conducted to ensure that oxygen settings matched each resident's orders. An education was provided to facility CNAs and licensed nursing staff to ensure accurate O2 settings in accordance with each resident's care plan. The DON or designee will complete observations of 5 residents a week x 8 weeks to ensure that resident O2 settings are in place in accordance with each resident's care plan. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.