Failure to Provide Physician-Ordered Respiratory Services
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for four out of five residents reviewed for respiratory care. Specifically, the facility's policy required oxygen tubing and masks/cannulas to be changed monthly and as needed if soiled or contaminated. However, multiple residents with significant medical histories, including dementia, anxiety disorder, hypertensive heart disease, chronic kidney disease, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease, did not have their oxygen tubing changed according to physician orders or facility policy. For example, one resident's tubing was last changed over a month prior and was not replaced on the scheduled date. Another resident's tubing was only changed after the issue was brought to the attention of the DON by the surveyor. Observations revealed that several residents' oxygen tubing was overdue for replacement, with one instance of tubing appearing yellowed. Documentation and interviews confirmed that the required monthly changes were not completed as scheduled for these residents. The DON acknowledged that the tubing had not been changed according to the established schedule, confirming the facility's failure to follow physician orders and its own policy regarding respiratory care.