Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents receiving oxygen therapy. One resident was observed receiving oxygen at 3.5 liters per minute (LPM) via nasal cannula, despite a physician's order specifying 2 LPM. The resident reported not adjusting the oxygen settings themselves. Another resident was observed with a nebulizer mask left unbagged on the bedside table and was receiving oxygen at 4–4.5 LPM, while the physician's order called for continuous oxygen at 5 LPM via nasal cannula. This resident also had orders for scheduled nebulizer treatments. The resident stated that only nurses handled the oxygen equipment. A third resident was observed with a nebulizer mask left unbagged on the bedside table, contrary to facility expectations that such equipment be stored in a plastic bag with a date. Staff interviews confirmed that the nebulizer mask should have been properly stored when not in use. Physician orders for this resident included as-needed nebulizer treatments for shortness of breath or wheezing. The DON confirmed the expectation for correct oxygen settings and proper storage of respiratory equipment.