Failure to Provide Safe and Appropriate Respiratory Care and Follow Pulmonology Recommendations
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for two residents. For one resident with a history of pneumonia and moderate cognitive impairment, staff did not store the nebulizer mask in a sanitary manner. Observations on multiple occasions revealed the mask was left uncovered on the bedside table, contrary to facility expectations that it should be stored in a plastic bag labeled with the date, time, and resident name. This failure was confirmed by staff interviews. For another resident with severe cognitive impairment and a history of altered respiratory status and pneumonia, the facility did not implement pulmonology consult recommendations. These recommendations included titrating oxygen to maintain SpO2 above 92% and encouraging the use of incentive spirometry or a flutter valve for pulmonary toileting. The clinical record did not show evidence of orders or documentation for incentive spirometry, nor consistent monitoring or titration of oxygen as recommended. Oxygen use and monitoring were not documented after a certain date, despite ongoing recommendations and changes in the resident's condition. Staff interviews confirmed that recommendations from pulmonology consults were expected to be communicated and implemented, but in this case, orders for incentive spirometry were not placed, and oxygen saturation monitoring was not consistently performed. The facility's policy addressed oxygen administration but did not provide guidance on incentive spirometer use. The deficiencies were brought to the attention of facility administration and nursing leadership.