Failure to Provide Respiratory Care per Physician Orders and Standards
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician's orders and accepted professional standards for two residents requiring respiratory support. For one resident with an order for oxygen at 2 liters per minute (lpm) via nasal cannula to maintain oxygen saturation above 90%, observations showed the oxygen concentrator was set at 1.5 lpm on multiple occasions. The resident reported that the prescribed setting was 2 lpm and expressed reluctance to request an adjustment. Documentation confirmed the order for 2 lpm, and the care plan reflected this intervention, but staff were unaware of the discrepancy and could not explain how oxygen saturation was being maintained as ordered. For another resident using a CPAP machine, there were no active orders in the medication administration record regarding the CPAP, including settings, maintenance, or cleaning instructions. The resident reported that staff had never cleaned the CPAP mask, and repeated observations revealed visible debris and oily substances on the mask. Staff interviews confirmed a lack of knowledge and responsibility for CPAP care, and the Director of Nursing was unable to locate any active orders or confirm proper maintenance. These findings demonstrate a failure to ensure respiratory care was provided as ordered and according to facility policy.