Failure to Provide Safe and Appropriate Respiratory Care and Emergency Response
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's provision of respiratory care for three residents receiving oxygen therapy. For one resident, oxygen tubing was observed on the floor and not labeled with the date opened, contrary to facility policy, which requires tubing to be dated and kept off the floor to prevent contamination. A certified nursing assistant confirmed the tubing should not touch the floor due to infection control concerns, and the Director of Nursing stated that tubing should be changed if it comes into contact with the floor. Another resident, with a history of acute respiratory failure, pneumonia, and COPD, was not monitored or assessed according to physician orders and the care plan. The nursing staff failed to titrate oxygen as ordered for low oxygen saturation, did not consistently assess or document abnormal vital signs, and did not promptly notify the physician when the resident exhibited low and fluctuating blood pressure and oxygen saturation. Interviews revealed that abnormal blood pressure readings were sometimes omitted from documentation, and there was confusion among staff regarding the resident's code status and the appropriate emergency response. The facility's emergency response system was not activated in a timely manner, and there was a delay in calling 911 after the resident was found unresponsive with critically low oxygen saturation. Additionally, another resident's nasal cannula was not dated or stored in a clean bag when not in use, as required by facility policy. These practices placed residents at risk for infection and, in the case of the resident with acute respiratory failure, resulted in the resident being found dead upon EMS arrival. The facility's policies on oxygen administration, monitoring, and emergency response were not followed, and staff interviews confirmed lapses in documentation, assessment, and adherence to established procedures.