Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for several residents. For one resident with hemiplegia and a history of traumatic cerebral hemorrhage, physician orders required oxygen therapy to be administered at 2 liters per nasal cannula if oxygen saturation fell below 92%. However, repeated observations showed the oxygen concentrator was set to 3 liters, the nasal cannula was often not in use or was found on the floor or bed, and the concentrator itself was dirty with visible debris and food splatters. Staff interviews confirmed the resident was supposed to have continuous oxygen, but also noted non-compliance by the resident and acknowledged the concentrator was unclean. Another resident with COPD, congestive heart failure, and cerebral infarction had orders for oxygen at 2 liters per nasal cannula and for the concentrator and filter to be kept clean. Observations on multiple occasions revealed dust and grime buildup on both the concentrator and its filter. The DON confirmed the equipment was in need of cleaning during an on-site review. A third resident with COPD, bipolar disorder, dementia, and hyperlipidemia had orders for inhaled ipratropium-albuterol via nebulizer. The nebulizer mask tubing at the bedside was found to be dated nearly a month prior, indicating it had not been changed weekly as required by facility policy. Staff confirmed the tubing had not been replaced in accordance with procedures. These findings demonstrate failures to maintain clean respiratory equipment, ensure correct oxygen flow rates, and timely change of nebulizer tubing as per physician orders and facility policy.