Failure to Provide Safe and Appropriate Respiratory Care and Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for multiple residents. For one resident with a tracheostomy, required tracheostomy care was not provided according to physician orders and facility policy. Observations revealed the absence of a tracheostomy obturator at the bedside over several days, and staff were unable to locate or demonstrate where the obturator was kept. Additionally, staff referenced practices not included in the facility's tracheostomy care policy, such as daily tracheostomy tube changes by a respiratory therapist. The facility also failed to obtain physician orders for oxygen therapy for two residents who were observed receiving oxygen via concentrator and nasal cannula at various flow rates. Despite ongoing administration of oxygen, there were no corresponding physician orders in the medical records until after surveyor intervention. Staff interviews confirmed the lack of orders and acknowledged the necessity of having them to guide care. Furthermore, the facility did not follow physician orders for oxygen therapy for three residents. Observations showed that oxygen was administered at flow rates higher than prescribed, and in one case, the oxygen concentrator was set to zero before being corrected. Staff acknowledged these discrepancies during interviews and made adjustments to the oxygen settings only after surveyor involvement. These failures were documented with photographic evidence and were consistent across multiple residents with varying degrees of cognitive impairment and complex respiratory needs.