Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents requiring oxygen therapy, as evidenced by multiple deficiencies in physician orders, care planning, and equipment maintenance. Two residents with diagnoses including chronic respiratory failure, COPD, and acute respiratory distress were observed receiving continuous oxygen therapy without corresponding physician orders or care plans addressing their oxygen use. Nursing staff confirmed the absence of orders and care plans, and acknowledged that these residents were on oxygen for shortness of breath, but had not obtained the necessary documentation. Another resident, who had a physician order and care plan for oxygen at 3 liters per minute (LPM), was observed receiving oxygen at a higher rate of 5 LPM. Nursing staff and the wound nurse verified the incorrect setting, and the nurse adjusted the concentrator to the ordered rate after the discrepancy was identified. The DON and Administrator both stated that nurses are expected to follow physician orders for oxygen therapy and to check settings regularly. A fourth resident, with severe cognitive impairment and a history of respiratory failure and COPD, was observed with a visibly dirty oxygen concentrator filter on multiple occasions. Nursing and administrative staff acknowledged that the filter should have been cleaned when the oxygen tubing was changed, and that both maintenance and nursing staff share responsibility for ensuring filters are clean. Facility policy and in-service records indicated that filters should be cleaned according to manufacturer recommendations and when visibly soiled, but this was not done in this instance.