Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care received services in accordance with professional standards of practice. Surveyors observed that for several residents receiving supplemental oxygen, the oxygen tubing was not labeled or dated to indicate when it had last been changed, despite facility policy and physician orders requiring weekly changes and labeling. This was noted repeatedly for multiple residents during different observations, and staff interviews confirmed that labeling was expected but not consistently performed. In addition, one resident did not receive supplemental oxygen as ordered by the physician, with discrepancies noted between the prescribed oxygen flow rate and the amount actually being delivered. Documentation was also incomplete, with missing records for oxygen administration on certain shifts. Staff interviews acknowledged that the delivery of oxygen must match physician orders and that documentation lapses could indicate missed care. Furthermore, the facility did not ensure that BiPAP equipment used by two residents was appropriately cleaned and maintained to prevent respiratory infections. There were no documented interventions or orders for cleaning and maintenance of the BiPAP equipment until after surveyor observations, and refusals of BiPAP therapy by a resident were not consistently documented or communicated to the physician. Staff interviews confirmed that cleaning protocols and documentation were required but not followed as per facility policy.