Failure to Maintain Respiratory Equipment Standards
Penalty
Summary
The facility failed to maintain respiratory equipment according to professional standards of practice for two residents. Resident R17, who has a history of chronic diastolic congestive heart failure and atrial fibrillation, was observed using an oxygen concentrator at 3 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. Additionally, the oxygen tubing for Resident R17 was not dated, which was confirmed by a licensed nurse during the observation. Resident R56, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, was observed using an oxygen concentrator at 6 liters per minute via nasal cannula. The humidifier bottle and oxygen tubing for Resident R56 were also not dated, as confirmed by the same licensed nurse. The facility's policy requires oxygen tubing to be changed weekly, but the lack of dating on the equipment indicates non-compliance with this policy.
Plan Of Correction
1. Resident R17 and R56 had not suffered any adverse reactions and oxygen tubing was changed/dated. 2. The Director of Nursing or designee will complete an initial audit of all residents receiving oxygen therapy to ensure oxygen tubing changed per Physician order for the last 7 days. 3. NPE/IP or designee will re-educate licensed nurses on Oxygen Therapy Management to ensure oxygen tubing changed per physician order. 4. DON or designee will conduct weekly audits x 12 weeks on 5 random residents to ensure Oxygen tubing was changed per physician order to ensure compliance. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.