Deficiencies in Respiratory Care and Oxygen Therapy Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents who required oxygen therapy. For one resident, the nasal cannula tubing was observed to be neither labeled nor dated as required by the facility's policy and procedures. Additionally, the tubing was not stored in a set-up bag when not in use, but instead was left coiled on top of the oxygen concentrator. The Director of Nursing (DON) confirmed these findings and acknowledged that the tubing should have been labeled and stored properly to maintain cleanliness and infection control. For another resident, the facility did not identify or address respiratory changes in a timely manner. The resident was observed coughing and wheezing, with oxygen saturation levels dropping significantly during the surveyor's presence. Despite these symptoms and a documented drop in oxygen saturation, there was no evidence in the medical record that a care plan was developed to address the resident's desaturation and moist cough. Nursing staff confirmed that documentation of a change in condition was completed, but the care plan was not updated to reflect the resident's current respiratory status. The facility's policies require that oxygen therapy supplies be changed, dated, and stored appropriately, and that any change in a resident's condition be assessed, documented, and care planned. In both cases, these procedures were not followed, resulting in deficiencies in the provision of safe and appropriate respiratory care for the affected residents.