Failure to Maintain Ordered Oxygen Saturations and Clean Respiratory Equipment
Penalty
Summary
The facility failed to maintain oxygen saturations according to provider orders and did not ensure that respiratory equipment, specifically a CPAP mask, was cleaned and maintained for a resident with respiratory and heart failure. The resident, who was cognitively intact and dependent on supplemental oxygen, was observed wearing oxygen at higher flow rates than ordered, with documentation showing administration of 3-5L of oxygen when the provider's order specified 1-2L per minute. Additionally, the resident's oxygen saturations were recorded above the recommended range for individuals with COPD, and there was no evidence that staff adjusted the oxygen back down or re-checked and documented the saturations as required. The CPAP mask used by the resident was observed to have white spots inside, and the resident reported that the facility had not cleaned the CPAP. There were no orders for cleaning the CPAP mask in the medication or treatment administration records, and staff interviews confirmed that cleaning protocols were not consistently documented or followed. The Director of Nursing acknowledged the absence of cleaning orders and the importance of routine cleaning to prevent infection. These failures were identified through observation, interview, and record review, and placed the resident at risk for illness and decreased quality of life.