Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents. For one resident with metabolic encephalopathy, dementia, dysphagia, and diabetes mellitus type two, physician orders specified continuous oxygen at two liters per minute via nasal cannula. However, during multiple observations, the resident's oxygen was set at 3.5 liters per minute, exceeding the prescribed dose. Nursing staff had documented that the oxygen was set correctly, but direct observation contradicted these records. For another resident with COPD, dysphagia, and dependence on supplemental oxygen, the nebulizer machine was found stored directly on the floor, with the mouthpiece in contact with both the machine and the wall, and the top of the machine covered in an unknown dried substance. The resident reported that nurses stored the nebulizer on the floor due to lack of table space and expressed a preference for it not to be stored there. These findings were confirmed by an LPN during the survey.