Failure to Follow Physician Orders for Oxygen and CPAP Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following physician orders for oxygen and CPAP administration. One resident, who had an order for continuous oxygen at 2 L per minute via nasal cannula, was repeatedly observed without oxygen or with an empty oxygen tank attached to her wheelchair. The resident's room lacked the required oxygen warning sign, and multiple empty oxygen tanks were present. Documentation indicated that oxygen was administered only 92% of the time, despite the order for continuous use. Another resident, who had an order for nightly CPAP use for obstructive sleep apnea, had not used the CPAP machine for an extended period. The CPAP equipment was found buried, dusty, missing a power cable, and without a current biomedical inspection date. Despite this, staff documentation reflected that the CPAP was applied most nights, which was inconsistent with the resident's statements and the observed condition of the equipment. The order for CPAP was eventually removed, but the order to clean the facemask remained.