Failure to Provide Safe and Appropriate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for three residents. For one resident with severe cognitive impairment and a history of dementia, anxiety, and legal blindness, the oxygen concentrator was not set to the physician-ordered flow rate of 2 liters per minute, and there was no documented indication for oxygen use. Additionally, staff failed to replace a nasal cannula that had been contaminated after falling on the floor, instead placing the soiled cannula back on the resident. The resident's care plan also lacked documentation regarding oxygen use or a corresponding diagnosis. Another resident, who was cognitively intact and had diagnoses including COPD and respiratory failure, was observed using an oxygen concentrator with a gross particle air intake filter that was coated in thick dust over multiple days. The filter had not been cleaned in accordance with manufacturer guidelines, and nursing staff were unaware of the proper cleaning process. Facility policy and the device manual both require regular cleaning of the filter to prevent contamination and ensure proper function. A third resident, diagnosed with obstructive sleep apnea and using a CPAP machine nightly, did not have physician's orders in place for the care and maintenance of the CPAP equipment. The CPAP mask was found with dried debris and was not stored in a bag as required, while the humidifier chamber contained significant buildup and debris. Staff confirmed that regular cleaning and maintenance of the CPAP equipment had not been documented or performed, and the resident reported that staff did not clean the equipment regularly.