Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Surveyors observed multiple failures in the provision of respiratory care for six residents requiring oxygen therapy. Oxygen equipment, including nasal cannulas and tubing, was found not properly contained, labeled, or dated in several resident rooms. In some cases, oxygen tubing was left hanging on tanks or concentrators, touching the floor, or not stored in a clean manner, contrary to facility policy and infection control standards. Additionally, oxygen equipment was not consistently bagged when not in use, and there was a lack of labeling to indicate when tubing was last changed, despite physician orders and facility protocols requiring weekly changes and proper documentation. Further deficiencies included the absence of required signage indicating oxygen was in use in resident rooms, as observed with one resident receiving oxygen therapy without any visible warning sign. Staff interviews confirmed that signage should have been present and that its absence was an oversight. In another instance, a resident's oxygen concentrator was set at a higher flow rate than prescribed by the physician, with both the resident and a registered nurse acknowledging the discrepancy. This failure to follow physician orders for oxygen flow rates was noted as a direct deviation from the resident's care plan and medical orders. The residents affected had significant medical histories, including chronic obstructive pulmonary disease, emphysema, acute respiratory failure, and other serious conditions requiring careful respiratory management. Documentation reviewed by surveyors showed that care plans and physician orders specified the need for monitoring, proper storage, and regular changing of oxygen equipment. Despite these directives, staff did not consistently adhere to established protocols, resulting in lapses in safe and appropriate respiratory care for all six residents reviewed.