Deficiencies in Respiratory Care Administration and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the provision and documentation of respiratory care, including oxygen therapy, nebulizer treatments, and BIPAP equipment maintenance for several residents. In several cases, oxygen was not administered according to physician orders, and there was a lack of documentation regarding the administration and reasons for PRN oxygen use. For example, one resident received continuous oxygen therapy at varying rates without documentation of the reason for administration or the specific amount delivered, despite having a physician order specifying PRN use and titration parameters. Another resident received oxygen at a rate exceeding both the physician's order and the facility's policy for nasal cannula use, with no attempt to titrate the oxygen to the lowest effective rate as required. Additional deficiencies were observed in the handling and maintenance of respiratory equipment. One resident's oxygen tubing was found touching the floor, and another's oxygen tubing was not labeled or dated as required by facility policy. A resident's nebulizer machine, mask, and tubing remained at the bedside undated and not stored in a clear plastic bag after the physician's order for nebulizer treatments had been discontinued. For a resident using a BIPAP device, there was no documentation that the tubing assembly, water tub, and mask were regularly cleaned as recommended by the manufacturer's user guide and facility policy, and the available logs did not specify when cleaning occurred. Surveyors also found that physician orders for oxygen therapy were not consistently followed. In one case, a resident was observed receiving oxygen at a higher rate than ordered, and in another, a resident had an active order for oxygen therapy that was not being implemented or discontinued in a timely manner. Interviews with nursing and respiratory staff confirmed the lack of adherence to orders and documentation requirements, and facility leadership acknowledged these findings during the survey.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 36, 54, 69, 80, 86, 89, 104, 122 were affected by this deficient practice. Immediately, Licensed nurse updated the plan of care for residents 36, 86, 89, 104, 122. Licensed nurse immediately replaced oxygen tubing that was touching the floor for resident 69 and replaced tubing of 80 with no label. On 7/18/2025, Respiratory Therapist supervisor reviewed the BIPAP user guide manual and provided 1:1 education to RT 1 about BIPAP cleaning guidelines and documentation. On 7/16/2025, DON provided 1:1 education to LVN 2 and 12 regarding oxygen administration and making sure to document when providing PRN order. On 8/5/2025-8/8/2025, DON in-serviced all Licensed Nurses about facility policy and procedure of developing a comprehensive care plan for each resident, in particular the care plan for oxygen administration. DON in-serviced also about policy and procedure for assessing residents' medical needs to make sure the plan of care was updated and documenting when providing oxygen as needed. DON also in-serviced about oxygen setting monitoring and following physician orders. On 8/5/2025-8/8/2025, RT supervisor in-serviced all Licensed Nurses about facility policy and procedure for managing and maintaining BIPAP machine which included cleaning schedule and making sure it was documented when cleaning and replacing parts of the BIPAP, such as tubings and mask. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents receiving oxygen could potentially be affected by this deficient practice. DON and Unit managers audited all residents' care plans who were receiving oxygen and found no other issues. DON will provide ongoing education and training to Licensed nurses about developing comprehensive care plans for individual residents. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. DON or designee will review all new admissions and re-admissions for oxygen orders and will make sure comprehensive care plans are developed to include oxygen parameters, especially for residents receiving oxygen. Any findings will be reviewed and reported during clinical meetings. Department Heads and designee will do daily room rounds to ensure all oxygen tubings are labeled and not touching the floor. Any issues will be addressed immediately and reported to the morning meeting for three months. Medical record audits will be conducted to ensure oxygen orders reflect residents' oxygen administration parameters every three months, with reports to the DON for any non-compliance. The Respiratory Therapist will review BIPAP cleaning and maintenance logs monthly to ensure RTs are following the user guide manual for cleaning and maintenance of BIPAP. Any non-compliance will be reported to the DON for three months. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON and Administrator will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented at the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- F0698 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 9 was affected by this deficient practice. Immediately on 7/23/2025, RN Supervisor assessed Resident 9's dialysis access site and found it to be in working order with no issues noted—bruit and thrill were present on assessment. Resident 9's plan of care was updated by RN supervisor to ensure dialysis access site was being assessed every shift. On 7/23/2025, DON provided 1:1 education to LVN 8 about facility policy and procedure for assessing dialysis access site and to ensure it was being documented in the resident's medical record. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All dialysis residents were potentially affected by this deficient practice. RN supervisor and Unit managers reviewed all dialysis residents and found no other issues. From 8/5/2025-8/8/2025, DON in-serviced all Licensed nurses about facility policy and procedure for assessing dialysis access sites, ensuring they are assessed every shift and as needed for functionality, and reporting any issues to the primary physician. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all new dialysis residents to ensure dialysis access sites are assessed every shift. The IDT team will review during clinical meetings to ensure the plan of care is being followed. Medical record audits will be conducted to review care plans and MAR for assessing dialysis access sites, with any non-compliance reported to the DON for three months.