Failure to Provide Physician-Ordered Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents. One resident with a history of acute respiratory failure with hypoxia and cellulitis of the right lower limb was observed not using his prescribed oxygen concentrator, stating he used it only when he felt it was needed. Despite a physician's order for continuous oxygen at 3 liters per minute via nasal cannula, documentation showed the resident was frequently on room air with varying oxygen saturation levels, and nursing staff did not contact the physician to update or discontinue the order as required. Another resident, diagnosed with diabetes and requiring assistance with personal care, was observed with CPAP nasal pillows left uncovered on the bedside table. The resident reported that it had been a while since staff had cleaned the mask and had never seen the humidifier cleaned. Facility policy required daily cleaning of the CPAP mask and weekly cleaning of the humidifier, with documentation in the patient record. However, there was no documentation of mask cleaning on a specific date, and the DON confirmed that nurses were not cleaning the mask or humidifier according to the physician's order and care plan.