Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide specialized respiratory care in accordance with professional standards for three residents. Resident R42, who was admitted with diagnoses including COPD and diabetes, was observed with an oxygen concentrator that had missing and soiled components. The tubing and humidifier were not dated, and the filter sponge was missing, with visible debris in the filter chamber. This was confirmed by a Unit Manager RN during an observation. Resident R235, admitted with COPD, diabetes, and toxic liver disease, had an empty humidification bottle, which was confirmed by a Unit Manager RN. Resident R811, with diagnoses including alcoholic cardiomyopathy and sarcoidosis of the lung, was observed with a nasal cannula connected to an empty, undated humidification bottle. The physician orders for Resident R811 did not include oxygen administration or equipment maintenance, despite the baseline care plan indicating oxygen as ordered. The Director of Nursing confirmed the facility's failure to meet professional standards for respiratory care for these residents.
Plan Of Correction
1. Oxygen concentrator for R42 was replaced, tubing and humidification bottle were changed. Humidification bottle for R235 was changed. Physician orders for oxygen were obtained for R811, oxygen tubing and humidification bottle were changed. 2. Director of nursing or designee will do a house audit of residents requiring oxygen to ensure orders are present for weekly changes of oxygen delivery equipment. 3. Director of nursing or designee will educate licensed nursing staff on following physician orders for changing oxygen delivery equipment and dating oxygen tubing and bottles when put in use. 4. Director of nursing or designee will audit 5 residents requiring oxygen weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure that orders for changing oxygen delivery equipment are present and tubing and humidification bottles are dated.