Deficient Respiratory Care: Incomplete Oxygen Orders, Poor Tubing Documentation, and Infection Control Lapses
Penalty
Summary
The facility failed to ensure that oxygen therapy orders for several residents included a specific rate of oxygen delivery. Observations revealed that multiple residents were receiving oxygen via nasal cannula, but their provider orders only specified to maintain oxygen saturation above a certain percentage, without indicating the exact flow rate. In some cases, contradictory orders were present, and staff interviews confirmed that orders often lacked a defined rate, especially when transferred from hospital records. This omission was noted for four residents, with staff acknowledging the issue and attributing it to the electronic medical record systems used. Additionally, the facility did not maintain proper documentation or labeling to indicate when oxygen tubing was last changed for several residents. During observations, none of the oxygen tubing in use had visible dates or labels showing the last change, despite facility policy requiring weekly changes and documentation. Staff interviews revealed uncertainty about where or if tubing changes were documented, and it was noted that a recent staffing mix-up may have contributed to the lack of labeling. A whiteboard in the nurse's lounge outlined the process, but this was not consistently followed in practice. Furthermore, infection control practices were not adhered to regarding respiratory equipment. One resident's nebulizer machine and mouthpiece were observed on the carpeted floor next to a trash receptacle, with the mouthpiece touching the floor and covered with used tissues. Staff confirmed that this did not meet infection control standards and acknowledged that the resident was unlikely to have placed the equipment there independently. The resident had a current order for nebulized albuterol four times daily, indicating frequent use of the equipment.