Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with multiple diagnoses, including dementia, congestive heart failure, abnormal lung findings, and hypoxia. The resident's medical record lacked documentation of an active order for oxygen therapy and did not include dosing instructions for oxygen administration. Additionally, the care plan did not address the use of oxygen therapy or BiPAP, despite the presence of related physician orders and equipment provided by hospice. Observations revealed the resident using oxygen tubing at the dining table, and on another occasion, the tubing was left unbagged directly on the table. Interviews with staff confirmed that oxygen equipment should be stored in a sanitary manner, such as in a bag when not in use, and that a specific physician order with dosing instructions was required for oxygen administration. Staff also acknowledged that respiratory care, including the use of BiPAP, should be included in the resident's care plan. The facility's own policy required safe administration and storage of oxygen, which was not followed in this case.