Failure to Follow Physician Orders and Infection Control Practices in Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care as ordered by physicians for four residents reviewed. Multiple residents were observed receiving oxygen at flow rates higher than those prescribed in their physician orders. For example, one resident was receiving oxygen at 4 liters per minute via nasal cannula, despite an order for 2 liters per minute as needed for shortness of breath. Another resident with a tracheostomy and a speaking valve was also observed with oxygen set at 4 liters per minute, contrary to the physician's order for 2 liters per minute. Staff interviews confirmed that the oxygen flow rates being administered did not match the physician orders, and staff were not always aware of the correct prescribed rates. Additionally, a third resident was observed receiving oxygen at 4 liters per minute when the order specified 3 liters per minute as needed, with physician notes indicating a range of 2-3 liters to maintain oxygen saturation above 92%. In another instance, a resident's nebulizer mask was repeatedly found unbagged and left on top of a drawer when not in use, despite physician orders and facility policy requiring the mask to be bagged and changed weekly or as needed. Staff interviews confirmed that the nebulizer mask should have been bagged when not in use, and the DON acknowledged this expectation. Review of facility policy indicated that oxygen and respiratory equipment should be managed according to professional standards and infection control guidelines, including keeping delivery devices covered when not in use. These observations and interviews demonstrate that the facility did not consistently follow physician orders or its own policies regarding respiratory care and equipment management.