Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for several residents requiring oxygen therapy. For several residents with physician orders specifying that oxygen tubing should be changed when visibly soiled and labeled with the current date, observations revealed that the oxygen tubing in use was not labeled or dated as required. Staff interviews confirmed that nurses were responsible for labeling and dating the tubing, and staff acknowledged that the tubing should have been labeled according to orders and facility policy. Additionally, a portable oxygen tank was observed stored unsecured on a stool rather than in a proper stand or dolly, contrary to staff expectations and safe storage practices. One resident was observed receiving continuous oxygen therapy via nasal cannula, but there were no corresponding physician orders or care plan documentation for oxygen use in the medical record or medication administration record (MAR). Staff interviews confirmed that orders should have been present, including details such as oxygen flow rate, tubing changes, concentrator filter maintenance, and oxygen saturation monitoring. The absence of these orders and documentation was acknowledged by multiple staff members, including the LPN and Director of Nursing. Similar deficiencies were observed for other residents, including those with diagnoses such as COPD and pneumonia, where oxygen tubing was not labeled or dated despite clear physician orders. Staff consistently stated that the tubing should have been labeled and dated, and that orders for oxygen use should have been present and followed. The facility's own policy required verification of physician orders and adherence to protocols for oxygen administration, which was not consistently implemented for the residents reviewed.