Deficiency in Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care related to oxygen management for Resident R122. The facility's policy on 'Respiratory Therapy' requires that oxygen tubing and cannula be changed every seven days or as needed, and that equipment such as oxygen tubing, reservoir, and distilled water be obtained. However, during an observation, it was noted that Resident R122's oxygen tubing was not labeled with a date, which is a deviation from the facility's policy. This was confirmed by LPN Employee E24 during an interview. Resident R122, who was admitted on 6/24/22, has a medical history that includes hypertension, chronic obstructive pulmonary disease (COPD), and anxiety. The resident's physician orders dated 4/8/24 indicated that the resident should remain on 2-5 liters of high-flow oxygen and is oxygen-dependent every shift. However, the orders failed to specify the percentage of oxygen saturation to maintain comfort or the method of oxygen delivery. This omission was confirmed by RN Supervisor Employee E13, who acknowledged that the facility did not provide appropriate respiratory care related to oxygen management for Resident R122.
Plan Of Correction
Resident 122's nasal cannulas were replaced and dated immediately upon discovery by the licensed nurse. Current residents who require oxygen and/or nebulizer treatments have the potential to be affected. An initial audit of residents who require oxygen and/or nebulizer treatments will be conducted by the Director of Nursing/designee to ensure nasal cannulas are dated, care plans reflect need for oxygen and/or nebulizers, and orders are in place for oxygen. Licensed nursing staff will be reeducated on labeling/dating nasal cannulas and nebulizer tubing, implementing care plans for respiratory care, and obtaining MD orders for respiratory care. Audits of 5 residents will be conducted weekly x4 weeks by the Director of Nursing/designee to ensure compliance. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.