Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to multiple residents, as evidenced by observations, interviews, and medical record reviews. Several residents did not receive oxygen therapy as ordered by their physicians. For example, one resident was administered oxygen at a higher rate than prescribed, while another was not given the continuous oxygen at the specified rate. In both cases, staff verified the discrepancies between the physician's orders and the actual administration of oxygen. Infection control practices related to respiratory equipment were not consistently followed. Observations revealed that oxygen tubing and CPAP masks were not stored in sanitary conditions, with some tubing touching trash bins or the floor, and some masks not being kept in storage bags when not in use. Additionally, equipment such as nebulizer masks and oxygen humidifiers were found unlabeled and undated, contrary to facility policy. Staff interviews confirmed that these practices were not being adhered to, and in some cases, staff were unaware of their responsibilities regarding cleaning and storage of respiratory equipment. Documentation of respiratory care was also found to be lacking. There was no evidence in the medical records of the administration and effectiveness of PRN oxygen therapy for certain residents, despite facility policy requiring such documentation. Staff interviews further revealed confusion about who was responsible for cleaning and documenting the use of respiratory equipment, with some licensed nurses relying on CNAs for cleaning tasks, even though facility policy assigned this responsibility to licensed nurses. These failures were acknowledged by facility leadership during interviews.