Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure professional standards of practice in providing respiratory care for two residents who required supplemental oxygen. For both residents, surveyors observed that the oxygen concentrator filters were covered with a layer of gray dust over multiple days, indicating that the filters had not been cleaned as required. According to staff interviews, the filters should be cleaned weekly in conjunction with the changing of oxygen tubing, but this was not done for either resident. Additionally, both residents were receiving oxygen at flow rates higher than those ordered by their physicians. One resident, with severe cognitive impairment and a history of rheumatoid arthritis and oxygen dependence, was observed receiving oxygen at 4 liters, despite a physician order for 2 liters as needed to maintain oxygen saturation above 92%. The other resident, with moderate cognitive impairment and diagnoses including acute respiratory failure and chronic heart failure, was observed receiving oxygen at 3 liters, while the physician order specified 2 liters as needed for oxygen saturation below 90%. These failures were confirmed through record review and staff interviews.