Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as evidenced by multiple deficiencies in the administration and documentation of oxygen therapy, nebulizer treatments, and CPAP use. For one resident with severe cognitive impairment and multiple respiratory diagnoses, staff did not document oxygen administration, frequency of oxygen saturation monitoring, or maintenance of respiratory equipment. Observations revealed improper storage and dating of oxygen and nebulizer tubing, with equipment found on the floor and not consistently changed or documented as required. Another resident with moderate cognitive impairment and diagnoses including COPD and sleep apnea had a physician order for oxygen at night, but the care plan lacked any direction for oxygen or respiratory services. The resident's room contained a CPAP machine without a corresponding physician order or documentation on its administration or maintenance. The resident reported not using the CPAP due to faulty equipment, and staff were unclear about the presence and use of an oxygen concentrator. Documentation in the medical record and on the MAR/TAR was incomplete regarding both oxygen and CPAP use. A third resident with respiratory failure and COPD was observed with oxygen tubing that was not dated as required, despite an order to change tubing and clean the concentrator filter weekly. The resident confirmed that tubing was changed only after being informed of a state visit, and extra tubing was left in the room. Facility policies required physician orders, proper dating, and documentation for respiratory equipment, but these were not consistently followed, leading to lapses in safe and appropriate respiratory care.