Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Nursing staff failed to provide necessary respiratory care to a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure, and congestive heart failure, as indicated by physician orders and professional standards of practice. The staff did not properly assess or document the resident's baseline oxygen saturation (SpO2) level prior to administering oxygen therapy, nor did they consistently monitor and document oxygen saturation every shift as ordered. There was also a lack of documentation regarding respiratory assessments, including signs and symptoms of respiratory distress or shortness of breath, before and after oxygen therapy was provided. Observations revealed that the resident's oxygen tubing was compressed within the side rail, and the nasal cannula was not properly positioned in the resident's nose, which could have impeded oxygen delivery. Interviews with nursing staff indicated a lack of awareness and adherence to the physician's PRN order for oxygen therapy, with some staff keeping the resident on continuous oxygen without documented need or assessment. The care plan did not specify the frequency of monitoring, safe oxygen saturation ranges, or include detailed clinical examination or assessment instructions. Further review of facility policies and interviews with the Director of Nursing and other staff revealed that there was no specific policy for COPD or respiratory failure care, and staff were not fully aware of the standards of practice for respiratory care. The facility's policy on oxygen administration required monitoring for signs of hypoxemia and documentation of vital signs and resident response before and after therapy, but these practices were not consistently followed for this resident.