Deficiency in Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two residents. Resident R115, who was admitted with a diagnosis of diffuse traumatic brain injury, had a physician's order for oxygen to be administered at 2 liters per minute via nasal cannula to maintain an oxygen level above 92%. However, an observation on March 17, 2025, revealed that the oxygen was set at 2.5 liters per minute, and the tubing was not labeled. A licensed nurse confirmed the incorrect setting and adjusted it to the correct level. Resident R63, admitted with diagnoses including endocarditis, acute and chronic respiratory failure, and muscle weakness, had a physician's order for weekly oxygen tubing changes. An observation on March 18, 2025, showed that the oxygen tubing was labeled with a date of February 27, 2025, indicating it had not been changed weekly as required. A licensed practical nurse confirmed the tubing was overdue for a change.
Plan Of Correction
1. Resident R-115 has orders for Oxygen at 2/L min as needed for shortness of breath and will have Oxygen tubing dated and changed weekly when in use. Resident R-63 has Oxygen tubing dated correctly and changed weekly as per physician orders. 2. All residents with physician orders for supplemental Oxygen use will be assessed to ensure consistent respiratory care as per physician orders. 3. Nurse Educator/Designee will re-educate all professional nursing staff on the policy, "Oxygen Administration." 4. The DON/Designee will conduct random weekly audits times 2 months to ensure that residents who utilize supplemental Oxygen receive consistent respiratory care by labeling and dating Oxygen tubing weekly as per physician orders. 5. Audit results will be reviewed monthly by QAPI Committee.