Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents, as evidenced by observations, clinical record reviews, and staff interviews. For Resident 54, there was a physician's order to provide oxygen at 2 liters per minute via nasal cannula continuously, change the oxygen tubing every Saturday night, and ensure all tubing and nebulizer equipment was bagged when not in use. However, observations on multiple days revealed that the oxygen concentrator was set at 2.5 liters per minute, the nebulizer pipe was unbagged, and the tubing was dated February 23, 2025, indicating it had not been changed as required. Resident 54 confirmed that staff was supposed to change the tubing weekly. Similarly, for Resident 36, there were orders to change the nebulizer tubing and bag every Saturday night shift, label the tubing with the date, time, and staff initials, and ensure all equipment was bagged when not in use. Observations showed that the nebulizer pipe was unbagged, and the tubing was also dated February 23, 2025, suggesting it had not been changed for over a week. An unopened bag dated February 23, 2025, was found on the resident's bedside stand, indicating that the necessary equipment was available but not utilized. These findings were reviewed with the Nursing Home Administrator.
Plan Of Correction
1. Resident 54 tubing was changed immediately. Resident 36 tubing was changed immediately. 2. The Director of Nursing completed an audit on all residents requiring oxygen tubing including any needed devices that require oxygen tubing to be changed. 3. The Director of Nursing provided education to nursing staff to ensure all tubing is changed weekly. All residents requiring a tubing change is in the physician orders to be changed Every Saturday, nightshift. 4. The Director of Nursing and or designee will complete weekly random audits for four weeks and then monthly for three months to ensure tubing is being changed weekly. The Director of Nursing will bring audits to the monthly quality assurance meeting for review.