Failure to Provide Safe and Appropriate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, resulting in care and services that were not consistent with professional standards of practice. For one resident with a stoma, staff did not implement suctioning according to physician orders and used oral suction equipment for stoma suctioning, contrary to expectations and without clarifying the method or route with the provider. Additionally, this resident received oxygen therapy without a physician order, and staff did not update the care plan to reflect accurate physician orders. Two other residents receiving oxygen therapy did not have their oxygen delivered at the physician-ordered flow rates. One resident's oxygen was set below the prescribed rate, and the nasal cannula was visibly soiled with debris, while the oxygen concentrator filter was covered in dust. Staff were unaware of the need to clean the filter and only replaced tubing when requested by the resident. Another resident was observed receiving oxygen at a higher flow rate than ordered, and the humidifier water bottle attached to the oxygen concentrator was empty on multiple occasions, despite orders to replace it as needed. A fourth resident was observed with a visibly soiled nasal cannula that had not been changed for an extended period, and the oxygen concentrator filter was covered in debris. Staff confirmed the tubing was dirty and needed to be changed, and the filter required cleaning. Across these cases, staff did not consistently follow physician orders, facility policy, or professional standards regarding respiratory care, oxygen administration, and equipment maintenance.