Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring such care, as evidenced by direct observations, interviews, and record reviews. One resident with severe cognitive impairment and chronic obstructive pulmonary disease had a nebulizer mask left uncovered on the nightstand when not in use, contrary to professional standards and staff acknowledgment that it should have been covered to prevent possible infection. The facility did not have a specific policy regarding covering respiratory equipment when not in use, and responsibility was left to the nursing staff. Another resident, admitted with pneumonia and respiratory failure, was observed receiving oxygen at 4 liters per minute via nasal cannula without a corresponding physician order. The care plan indicated oxygen therapy as ordered, but no physician order for oxygen was found in the resident's records. Facility staff confirmed that the resident was receiving oxygen without an order due to an oversight in entering the order into the system, which was acknowledged as a mistake and inconsistent with the facility's own policy requiring physician orders for oxygen administration.