Failure to Provide Safe and Appropriate Respiratory Care per Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident as per physician orders. Observations revealed that the resident's nebulizer mask was left uncovered on the bedside table for multiple days, despite facility policy requiring respiratory therapy equipment to be bagged when not in use. Additionally, the resident was observed receiving oxygen via nasal cannula at 4 liters per minute without the required ear cushions or padding for skin protection, as ordered by the physician. These deficiencies were confirmed through interviews with the resident, who reported inconsistent use of nasal cannula cushions and irregular administration of nebulizer treatments, and with staff, who acknowledged the equipment was not properly stored and the required padding was not in place. Record review showed physician orders for Ipratropium-Albuterol nebulizer treatments every six hours as needed for shortness of breath, and for nasal cannula ear cushions or padding every shift to reduce pressure. Despite these orders, the resident's care did not consistently follow the prescribed protocols. The Director of Nursing confirmed that the facility's policy mandates bagging of respiratory equipment and adherence to physician orders for nasal cannula padding, but these procedures were not followed in this case.