Failure to Follow Physician Orders and Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not following physician's orders for oxygen administration, not updating care plans to reflect current oxygen orders, and not maintaining oxygen supplies in a sanitary manner. One resident, with COPD and other comorbidities, was observed completing a nebulizer treatment independently, after which a nurse placed the used nebulizer mask and tubing with medication residue into a plastic bag without cleaning or drying the equipment. This was confirmed by both the nurse and the Director of Nursing. Another resident with COPD and chronic respiratory failure was observed receiving oxygen at a rate different from the physician's order. The electronic medical record indicated an order for continuous oxygen at 4LPM, but the concentrator was set to 3LPM. Additionally, after the order was updated to allow a range of 2LPM-4LPM, the care plan and Kardex still reflected the previous order of 4LPM continuous, resulting in inconsistent documentation and care instructions. A third resident, with a history of CHF and other conditions, was found with an oxygen concentrator and nasal cannula tubing in their room, despite having no physician's order or care plan for supplemental oxygen. The tubing was undated, uncontained, and showed signs of use. Therapy staff reported that the resident had been given oxygen during therapy sessions at the direction of nursing staff, but there was no documentation or order for this intervention in the resident's medical record.