Inadequate Respiratory Care for Multiple Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for six residents, as evidenced by observations, staff interviews, and clinical record reviews. Resident R31's nebulizer tubing and mask were not dated or stored in a bag for infection control purposes. Resident R42's oxygen tubing was not dated and initialed as required by the physician's order. Resident R74's oxygen humidification bottle was empty and not dated, and the nebulizer tubing was not stored properly. Resident R81's oxygen tubing was not changed weekly, and there was no physician's order or care plan intervention for oxygen therapy. Resident R203, who required oxygen at 5 liters per minute, did not have a humidification bottle attached to the oxygen concentrator, causing discomfort. Resident R253 was observed receiving oxygen at 4 liters per minute instead of the ordered 5 liters, due to a suspected issue with the concentrator. These deficiencies indicate a failure to adhere to facility policies and physician orders regarding respiratory care, including proper labeling, storage, and equipment maintenance. The lack of compliance with these standards resulted in inadequate care for residents requiring respiratory support.
Plan Of Correction
R253's humidification bottle was added. R31, R42, R74, R81, and R203's O2/Neb tubing was changed and dated, bags provided for storage. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee completed an audit of current residents with oxygen therapy and nebulizer orders to ensure oxygen therapy is being delivered as ordered and tubing is dated and stored appropriately. Corrections will be made as needed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee licensed educated staff on the oxygen administration and nebulizer policy. To monitor and maintain ongoing compliance, the DON/designee will audit residents with oxygen therapy and nebulizers to ensure oxygen therapy is being delivered as ordered and tubing is dated and stored appropriately weekly x4 then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.