Failure to Ensure Safe Respiratory Care and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, resulting in deficiencies related to oxygen administration and CPAP use. For one resident with a history of hemiplegia, hemiparesis, and congestive heart failure, observations revealed that her oxygen concentrator was consistently set above the physician-ordered range of 2-4 liters per minute, with settings noted at 4.5 to 5 liters. The nasal cannula was also observed to be improperly applied on several occasions, and staff interviews indicated a lack of clarity regarding responsibility for verifying and adjusting oxygen settings. Another resident with diagnoses including pulmonary embolism and obstructive sleep apnea was observed using a CPAP machine without an active physician order for its use. The resident reported that her CPAP mask had never been cleaned since admission, and the mask was visibly soiled. Although there were orders for daily rinsing of the mask and weekly cleaning of the straps, staff interviews and documentation review revealed inconsistent cleaning practices and a lack of documentation for some days. Staff confirmed that a physician order was required for CPAP use, but none was present in the resident's record. Facility policy required review of physician orders for respiratory equipment and specified cleaning protocols. However, the observed practices did not align with these requirements, as evidenced by improper oxygen administration, lack of active orders for CPAP use, and inadequate cleaning of respiratory equipment. These failures were confirmed through staff interviews, record reviews, and direct observation.