Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents. For one resident with a history of acute respiratory failure and COPD, the care plan required continuous oxygen administration at 4 liters per minute via nasal cannula. However, during multiple observations, the resident's oxygen was found to be off and the nasal cannula was not properly positioned, contrary to the care plan instructions. The resident was dependent on staff for personal hygiene and mobility, and had moderate cognitive deficits, making self-management of oxygen therapy unlikely. For another resident with hemiplegia, hemiparesis following a stroke, and respiratory failure with hypoxia, the nebulizer mask and tubing were not changed in accordance with the facility's policy, which required weekly changes. The equipment was observed to be dated from several weeks prior, and staff confirmed that the mask and tubing were overdue for replacement. The facility's policy specified that nebulizer tubing and delivery devices should be changed weekly or as needed, and failure to do so could affect the delivery of medication.