Failure to Ensure Proper Respiratory Care and Tubing Management
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for residents requiring oxygen and nebulizer therapy. For multiple residents with diagnoses such as acute respiratory failure, hypoxia, COPD, and congestive heart failure, observations revealed that oxygen and nebulizer tubing were not labeled or dated to indicate when they were last changed. Staff interviews indicated a misunderstanding of responsibility, with some believing the oxygen vendor was responsible for changing and labeling tubing weekly, while the vendor clarified that the facility was responsible for this task. Review of facility policy and the vendor contract confirmed that the facility, not the vendor, was responsible for changing and labeling respiratory supplies, but the policy did not specify the required frequency or responsible party for tubing changes. Additionally, the facility failed to administer oxygen therapy according to physician orders. In several cases, residents were observed receiving oxygen at flow rates lower than those prescribed by their physicians. For example, one resident with a physician order for 2-3 liters per minute was found receiving only 1.5 liters per minute, and staff had to adjust the setting after this was identified. Another resident with a titration order to maintain oxygen saturation above 92% was also observed on a lower flow rate, though their saturation was within the target range at the time of observation. Care plans for some residents did not include interventions or focus areas related to the administration and management of oxygen therapy, despite active physician orders for such care. The facility's oxygen policy was reviewed and found lacking in guidance regarding the frequency of tubing changes and assignment of responsibility for this task. These deficiencies were identified through observations, record reviews, and interviews with staff, the DNS, and the oxygen vendor.