Failure to Document and Change Respiratory Equipment as Ordered
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required oxygen therapy and nebulizer treatments. Specifically, the facility did not ensure that nebulizer masks and oxygen cannulas were changed and documented according to physician orders and facility policy. Observations revealed that one resident's nasal cannula appeared dirty and there was no documentation in the electronic health record (EHR) indicating when it had last been changed. Interviews with the resident and her roommate provided conflicting accounts of when the cannula was last replaced, and staff interviews confirmed that the process for changing and documenting respiratory equipment was inconsistent. Record reviews for the three residents showed active orders for regular changing of oxygen and nebulizer tubing, masks, and cannulas, with specific instructions for weekly changes and documentation in the EHR. However, there was no evidence in the records that these changes were consistently performed or documented. Staff interviews revealed a lack of clarity regarding responsibility and routine for changing respiratory equipment, with some staff stating it should be done weekly, typically on Sundays, and others unsure of the exact process. The facility was also in the process of transitioning to a new EHR system, which contributed to gaps in documentation. The facility's own policy required weekly changing and documentation of oxygen and nebulizer tubing and masks by the nursing department. Despite this, the required documentation was missing, and direct observation confirmed that at least one resident was using respiratory equipment that had not been changed as required. This failure to follow established protocols and document care placed residents at risk for infection, as noted by staff during interviews.
Penalty
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Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
Surveyors found that two residents receiving respiratory treatments did not receive care consistent with professional standards. One resident with asthma and obstructive sleep apnea was observed twice receiving oxygen at 3 L/min via nasal cannula with undated oxygen tubing, despite an active order for oxygen therapy and a related care plan. Another resident with CHF and muscle weakness was observed twice with a nebulizer mask left uncovered on a table after use, despite an order for nightly albuterol nebulizer treatments and a care plan addressing breathing difficulty. The DON stated that oxygen tubing should be dated, nebulizer masks should be cleaned and put away after use, and acknowledged there were no facility policies for supplemental oxygen or nebulizer use.
Two residents with significant respiratory conditions, including COPD, CHF, pulmonary embolism with cor pulmonale, pleural effusion, asthma, and acute/chronic respiratory failure, were observed receiving oxygen via nasal cannula at specific flow rates, but their physician orders only directed oxygen via nasal cannula to maintain SpO2 above 92% with titration or weaning as tolerated, without specifying flow rate or complete device parameters as required by facility policy. Their care plans identified risk for altered breathing patterns and referenced “oxygen as ordered” but did not provide further instructions for oxygen therapy. The DON later acknowledged that the oxygen orders for these residents were unclear and incomplete.
Surveyors found that a resident with chronic respiratory failure and a tracheostomy did not have an Ambu (resuscitation) bag readily available at the bedside, despite facility policy requiring a handheld resuscitation bag with oxygen source to be easily accessible for emergencies; the RN confirmed the bag was missing and would have to be obtained from a crash cart if needed. In addition, another resident receiving continuous oxygen therapy at 3 L/min via nasal cannula had no corresponding physician order, which was confirmed on record review and by an LPN in social services.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Follow Professional Standards for Oxygen and Nebulizer Respiratory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care and services consistent with professional standards of practice for two residents who required such care. For one resident with asthma and obstructive sleep apnea, surveyors observed the resident in bed on two separate occasions receiving supplemental oxygen at 3 liters per minute via nasal cannula, with the oxygen tubing not dated either time. The resident’s care plan included a focus on potential complications related to asthma and restrictive lung disease with an intervention to provide oxygen therapy as ordered, and the physician’s order specified oxygen via nasal cannula at 2–4 liters per minute. The DON stated that oxygen tubing should have been dated when applied or changed and acknowledged that the facility did not have a policy regarding supplemental oxygen use. For another resident with diagnoses including heart failure and muscle weakness, surveyors twice observed the resident sitting in a recliner with her nebulizer mask left out on the table beside her, not covered or stored in a bag after use. The resident’s care plan addressed difficulty breathing due to CHF, and there was a physician’s order for albuterol sulfate solution via nebulizer daily at bedtime. The DON reported that she would expect the resident’s nebulizer mask to be cleaned and put away after use and confirmed that the facility did not have a policy regarding nebulizer use. The lack of specific policies and the observed handling of oxygen tubing and nebulizer equipment formed the basis of the cited deficiency under respiratory care requirements and related state nursing services regulations.
Plan Of Correction
1. Removed, replaced and dated oxygen tubing for resident identifier # 5. Nebulizer mask for resident identifier # 37replaced and placed in bag with date for storage when not in use. 2. Audit done to ensure that the oxygen tubing was dated properly and residents oxygen and nebulizer equipment was being stored correctly when not in use. Audit included order was in place on mar/tar for nursing staff to document completion of dating and changing. 3. Education provided to licensed staff on process for changing oxygen tubing and dating tubing correctly. Education on cleaning nebulizer equipment and storing oxygen and nebulizer equipment when not being used provider. 4. Audit of oxygen tubing dates and storage of equipment involving oxygen tubing and nebulizer will be done weekly X 1 month on 5 residents, biweekly for 1 month on 5 residents and then 5 audits X1 month. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Incomplete Oxygen Therapy Orders and Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that oxygen therapy was provided in accordance with professional standards of practice and physician orders for two residents who required respiratory care. Facility policy on oxygen utilization and storage required that physician orders for oxygen include the device, flow rate, and duration, including clear parameters for PRN use. For one resident admitted with acute and chronic respiratory failure, pneumonia, CHF, and COPD, observation showed oxygen being administered via nasal cannula at three liters per minute. However, the corresponding physician order only stated to provide oxygen via nasal cannula to keep pulse oximetry greater than 92% and allowed titration or weaning as tolerated, without specifying a flow rate or fully detailing the delivery device. The resident’s care plan addressed risk of altered breathing patterns related to multiple respiratory conditions and oxygen use, but the only intervention related to oxygen was “oxygen as ordered,” with no further instructions. For a second resident admitted with pulmonary embolism with cor pulmonale, pleural effusion, asthma, and acute and chronic respiratory failure, observation showed oxygen being administered via nasal cannula at six liters per minute. The physician order for this resident was similarly limited to oxygen via nasal cannula to keep pulse oximetry greater than 92% with titration or weaning as tolerated, again without specifying a flow rate or complete delivery parameters. The care plan for this resident also identified risk of altered breathing patterns related to multiple respiratory diagnoses and oxygen use, but listed only “oxygen as ordered” as the intervention, with no additional directions for oxygen therapy. The surveyor later notified the DON that complete oxygen orders could not be found for these two residents, and the DON confirmed that the oxygen orders were not clear and needed to be updated.
Plan Of Correction
1. The policy on Oxygen Utilization and Storage will be modified to ensure physician orders for oxygen include flow rate. 2. The licensed nursing staff will be in-serviced on policy changes. 3. All new oxygen orders will be completed in accordance with new policy. 4. As part of routine clinical meeting, the ADON will verify that oxygen orders are accurate and completed according to policy. 5. For the next 60 days, the ADON will complete an audit on all oxygen orders verifying accuracy. 6. The residents of the audits will be reported to the facility QA team.
Failure to Maintain Tracheostomy Emergency Equipment and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory and tracheostomy-related care and equipment for two residents. One resident, admitted with chronic respiratory failure with hypoxia, tracheostomy status, COPD, heart failure, and chronic pulmonary edema, had active orders for 28% humidified oxygen via tracheostomy collar to maintain oxygen saturation above 90%, with tracheostomy care every shift and a full code status. Her care plan identified risk for respiratory distress, decannulation, and infection, with interventions including humidified oxygen and tracheostomy care per orders and protocol. During an observation of tracheostomy care performed by an RN, the resident’s room was checked for emergency medical supplies related to her tracheostomy. All necessary emergency equipment was present except for an Ambu (resuscitation) bag, which could not be located despite the nurse searching the room. The RN acknowledged that an Ambu bag should be readily accessible in the room for emergencies and stated she would need to leave the room or have someone obtain one from the crash cart if needed. The facility’s tracheostomy care policy specified that a handheld resuscitation bag with attached oxygen source must be readily available for easy access in an emergency. The deficiency also includes the facility’s failure to ensure a physician’s order was in place for oxygen administration for another resident prior to its use. This resident was admitted with diagnoses including major depression and hypertension. An MDS assessment documented that the resident received continuous oxygen therapy. During an observation, the resident was noted to have oxygen in place at 3 L/min via nasal cannula. Review of current orders showed there was no physician’s order for the resident to receive oxygen. In a subsequent observation and interview, the resident was again seen resting in bed with oxygen in place, and a social services staff member, who is also an LPN, confirmed that there was no order in place for the oxygen therapy being administered.
Plan Of Correction
1. On 5/6/26, Director of Nursing verified an ambu bag at Resident #9's bedside. On 4/13/26 the Licensed Nurse contacted the physician and obtained an order for oxygen use for Resident #39. 2. Like Residents are identified as residents who utilize a tracheostomy within in the facility. Utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure they have an Ambu bag at bedside. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize oxygen within the facility. Utilizing the Respiratory Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure residents utilizing oxygen have physician orders for oxygen use in place. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Physician Orders, the emergency equipment to be at bedside for residents with a tracheostomy and the Use of Oxygen Policies to include obtaining physician orders for use of oxygen. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit all residents with a tracheostomy weekly for four weeks, beginning 5/14/26 to ensure they have an Ambu bag at bedside. Noncompliance noted from audits will be corrected with emergency equipment at bedside for residents with a tracheostomy. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Respiratory Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents utilizing oxygen have physician orders for oxygen use in place. Noncompliance noted from audits will be corrected with physician orders obtained for resident with oxygen use in place. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
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