Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in their treatment. Resident R32, who was admitted with diagnoses including respiratory failure, was observed receiving oxygen at 3 liters per minute (LPM) via nasal cannula, despite a physician's order specifying 1-2 LPM. This discrepancy was confirmed by a registered nurse, indicating a failure to adhere to the prescribed oxygen therapy. Resident R36, with diagnoses including Alzheimer's Disease and hyperlipidemia, was prescribed Ipratropium-Albuterol for congestion. However, the facility did not have a physician order to change the nebulizer tubing and aerosolized face mask, nor was there a care plan addressing the maintenance of respiratory equipment or procedures for adverse reactions. Interviews with staff, including the Director of Nursing, revealed that the facility lacked policies and procedures for respiratory care and aerosolized medication therapy, further confirming the deficiency in providing appropriate respiratory care for Resident R36.
Plan Of Correction
Resident 32 oxygen order updated for the liter flow of oxygen that was needed. All resident records evaluated to ensure that the physician order matched the delivery of liter flow. Staff re-educated that oxygen delivery will have an order and be in the care plan. Staff will also verify oxygen order to the oxygen concentrator each shift by the Director of Nursing or designee. Audits to be completed by the director of nursing or designee to ensure that the oxygen flow that the resident is receiving matches the physician orders. Audits completed weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reviewed with the QAPI committee. Resident 36 nebulizer tubing had been changed 1/24/25, per our normal procedure of changing on Thursday, night shift. Order written to change tubing/aerosolizer weekly. All residents' nebulizer tubing checked and verified MD order for changing the tubing weekly and noted in care plan. Staff education by the Director of nursing or designee completed on policy to add orders for the nebulizer tubing to be changed weekly for anyone ordered a nebulizer and anyone admitted with an order for nebulizer treatment. Change of tubing also to be noted in the care plan. QAPI will be done to ensure an order for nebulizer tubing changes is written for patients with a nebulizer. The director of Nursing or designee will audit residents with nebulizer treatments to ensure there is an order in place for changing the tubing weekly. Audits will be completed weekly for one month, bi-weekly for one month, and monthly thereafter. All results will be reviewed by the QA committee.