Deficiencies in Respiratory Care: Labeling, Documentation, and Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies in labeling, storage, and documentation of respiratory equipment and therapy. For one resident, the nebulizer tubing, mask, and canister were found unlabeled and not dated, with no indication of when they were last changed, despite a physician's order for regular nebulizer treatments. An LVN confirmed that these items should have been labeled and changed weekly or as needed. Another resident had a suction canister, tubing, and Yankauer suction tip that were not labeled or stored in a set-up bag, and the canister contained liquid of unknown age. The same resident was observed receiving oxygen at a rate higher than the physician's order, with no documentation of the administration or the reason for the increased flow. The LVN and RN involved confirmed the lack of labeling, improper storage, and missing documentation. A third resident was observed receiving oxygen therapy without a physician's order, and there was no documentation or reason for the administration. The DSD and LVN verified the absence of an order and documentation. Additionally, another resident's oxygen humidifier bottle was not dated as required by physician's order and facility policy. The DON acknowledged all these findings during interviews and record reviews.