Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide appropriate respiratory care to meet the needs of several residents, as evidenced by multiple deficiencies in documentation, administration, and maintenance of respiratory equipment. For one resident with chronic respiratory failure and obstructive sleep apnea, there were repeated failures to document the administration of BiPAP therapy across several months, including specific dates in November 2022, January 2023, November 2024, and June 2025. Additionally, there was an instance where the BiPAP was not administered due to equipment malfunction, and the absence of documentation made it unclear whether the therapy was provided as ordered. Other deficiencies included the administration of oxygen at incorrect flow rates and the lack of physician orders specifying the indication for oxygen therapy. One resident was observed receiving oxygen at a higher flow rate than prescribed, and the physician order did not include the required indication for use. Another resident's oxygen tubing was not changed according to the prescribed schedule, with tubing dated beyond the weekly change requirement, and the oxygen was administered at a higher rate than ordered. Staff interviews confirmed these findings, including the lack of proper documentation, failure to follow physician orders, and improper maintenance of respiratory equipment.