Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents as required by professional standards and physician orders. One resident with chronic obstructive pulmonary disease had a physician order for oxygen at 2-4 liters per minute via nasal cannula with humidity to maintain oxygen saturation above 90%. Observations revealed that the resident was repeatedly receiving oxygen at various flow rates without the required humidity, both from a portable tank and a concentrator. The resident also reported feeling she was not getting enough oxygen and was found with an almost empty oxygen tank, requiring staff intervention to switch to a concentrator. The Director of Nursing confirmed that staff should check oxygen tank levels and that humidity orders should be followed. Another resident with a physician order for CPAP every shift was observed with the CPAP mask hanging from the bed rail and not stored in the designated bag, which was undated and placed on the bedside table. The resident expressed concern about improper storage of the mask, and an LPN confirmed that the mask should be stored in the bag and not hung on the bed. Review of facility policy indicated that respiratory equipment should be used per physician orders and infection control techniques should be maintained, but these procedures were not followed for the residents involved.