Failure to Document and Provide Safe Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident with diagnoses including sleep apnea and edema. Although a physician ordered PRN oxygen therapy via nasal cannula for shortness of breath, there was no documentation of the start date, oxygen tubing changes, or cleaning of the oxygen concentrator filter. The facility's policy required detailed documentation for oxygen administration, but the Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained no entries regarding the resident's PRN oxygen therapy during the review period. Multiple observations and interviews confirmed that the resident regularly used oxygen, including while sleeping and during various shifts. Staff and therapy personnel also reported the resident's reliance on oxygen. Despite this, there was no documentation of oxygen use or required maintenance procedures, and the Director of Nursing Services confirmed the absence of a tubing and filter cleaning schedule. This lack of documentation and adherence to policy placed the resident at risk for unmet respiratory needs.