Failure to Provide Safe and Appropriate Respiratory Care and Accurate Documentation
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for two residents requiring oxygen therapy. For one resident with chronic obstructive pulmonary disease, observations revealed that oxygen tubing was not labeled or dated as required, and the resident reported the tubing had not been changed since admission. Staff interviews showed inconsistent understanding of when and how to change and label oxygen tubing, and the Director of Nursing confirmed the expectation for weekly changes with proper labeling, which was not met. For another resident with heart failure, respiratory failure, and obstructive sleep apnea, there was a lack of documentation in the care plan regarding the use of a Bi-pap machine, despite physician orders and the resident's need for the device. The Bi-pap machine was reported missing for an extended period, and the resident was not provided with the ordered therapy. Progress notes and treatment administration records contained discrepancies, with some staff documenting that the Bi-pap was provided when it was actually unavailable. The resident confirmed the machine had been missing and that he had not refused its use, while staff interviews corroborated the missing equipment and acknowledged inaccurate documentation. Facility policy required weekly changes and labeling of oxygen tubing, which was not consistently followed. The lack of proper respiratory equipment management, failure to provide ordered therapy, and inaccurate documentation contributed to the deficiencies identified for both residents.