Deficiencies in Oxygen Therapy Management and Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents, as evidenced by multiple deficiencies in oxygen therapy management. One resident with respiratory failure, pneumonia, and stroke was observed receiving oxygen at a rate higher than the physician's order, with the oxygen concentrator's air intake filter covered in dust. Staff interviews revealed a lack of knowledge regarding the cleaning schedule and manufacturer's instructions for the concentrator, and the resident's oxygen order was not followed until after the discrepancy was identified. The facility's policy required cleaning according to manufacturer guidelines, but this was not consistently implemented. Three residents receiving continuous oxygen therapy did not have required oxygen signage posted near their rooms, despite being observed with oxygen concentrators in use. Staff, including the unit manager and DON, were unaware that signage was missing and did not know it was required by facility policy. Additionally, two residents had not had their oxygen tubing changed as ordered, with tubing observed to be dirty and dated two weeks prior. Staff interviews indicated that tubing changes were missed due to lack of supplies and competing priorities during shifts, and management was not aware of the missed changes. Another resident was found to be on continuous oxygen without a physician's order or care plan intervention for oxygen use. The resident had been on oxygen for at least a week, and both the unit manager and nurse practitioner assumed an order was in place or that it had been missed. The DON confirmed that nursing staff should have ensured an order was entered when the resident began oxygen therapy, but this was not done. These findings demonstrate failures in following physician orders, maintaining equipment, ensuring proper documentation, and adhering to facility policies for respiratory care.