Failure to Provide Safe and Appropriate Respiratory Care and Adhere to Oxygen Protocols
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents with significant medical histories. For one resident with diagnoses including respiratory failure, deep vein thrombosis, pulmonary emboli, and congestive heart failure (CHF), the care plan did not address the resident's CHF, asthma, or recent pulmonary emboli, and lacked interventions, goals, or monitoring parameters related to CHF or respiratory distress. Documentation showed a decline in oxygen saturation over several days, with readings dropping as low as 72%. Despite the resident expressing concerns of shortness of breath and lower extremity edema, nursing staff did not perform a thorough assessment, such as auscultation of lung sounds, nor did they escalate the change in condition to a registered nurse or notify the provider in a timely manner. The resident was eventually found to be hypoxic and tachypneic, requiring emergency intervention and hospitalization for acute hypoxic respiratory failure and an acute onset of CHF. For another resident with diabetes, hypertension, and anxiety who required continuous oxygen, the care plan did not include oxygen use. Physician orders specified that oxygen tubing should be changed weekly, but observations revealed that the tubing had not been changed for 44 days, despite staff signing off on the treatment administration record that it had been changed weekly. The Director of Nursing confirmed that the tubing should have been changed according to the order and facility policy, and that the failure to do so could compromise infection control and oxygen delivery. Both deficiencies were identified through review of clinical records, facility policy, and staff interviews. The failures included lack of appropriate assessment and escalation for a resident with respiratory symptoms and CHF, and failure to follow physician orders and facility policy for oxygen tubing changes for a resident on continuous oxygen therapy.