Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care services for two residents, R146 and R149, as observed during a survey. Resident R146, who was admitted with diagnoses including Acute Respiratory Failure and COPD, had a physician's order for oxygen at 2 liters per minute via nasal cannula. However, during an observation, it was found that the oxygen flow meter was set at 5 liters per minute, contrary to the physician's order. This discrepancy was confirmed by the Director of Nursing, Employee E3, during a follow-up observation. Resident R149, admitted with diagnoses including COPD and Generalized Anxiety Disorder, was observed receiving oxygen therapy without a physician's order. The oxygen concentrator's flow meter was also set at 5 liters per minute, and the oxygen tubing and humidification bottle lacked proper labeling. The resident reported informing the staff about the issue, but no action was taken. The Director of Nursing and Unit Manager confirmed the absence of a physician's order for oxygen therapy for Resident R149.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents R146 and R149 were provided with respiratory care and supplemental oxygen as ordered by the physician. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Residents on oxygen will be audited to ensure they are MD orders are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that pain medications are in place and are being given as ordered. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.