Failure to Follow Physician Orders and Proper Storage Protocols for Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents by not following physician orders and established care plans. One resident with chronic respiratory failure and hypoxia was observed with their oxygen concentrator set at 3 liters per minute, despite a physician's order for 2 liters per minute via nasal cannula. The nasal cannula tubing was found on the floor and not in use, and staff confirmed the oxygen setting was incorrect. Another resident, who was ventilator dependent and severely cognitively impaired, was found lying in bed with the head of bed elevated only 10 to 20 degrees, contrary to the physician's order and care plan requiring elevation above 45 degrees. The resident was noted to be flushed and gasping for air until staff intervened to reposition and suction the resident. Additionally, the facility did not maintain proper storage and labeling of oxygen nasal cannula tubing for two residents. In one case, a resident's oxygen tubing was found hanging on a wheelchair, touching the floor, undated, and not stored in a plastic bag. In another case, a resident's nasal cannula tubing was hanging on the oxygen concentrator tank, also undated and not in a plastic bag. Staff acknowledged that the tubing should be dated and stored in a plastic bag when not in use to prevent contamination and maintain hygiene. The facility's own policies require oxygen to be delivered according to physician orders and for equipment to be maintained and stored properly. Interviews with staff, including the interim DON and respiratory therapists, confirmed that these expectations were not met in the observed cases, resulting in deficiencies in respiratory care for the affected residents.