Deficiencies in Respiratory Care and Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and services for several residents requiring oxygen therapy and CPAP support. For one resident using a CPAP machine, there was no documented physician's order, no care plan, and no evidence of care or maintenance of the device in the medical record. The resident reported that she and her family were solely responsible for cleaning and maintaining the CPAP machine, with no involvement from facility staff. Observations and interviews confirmed that staff were aware of the device but did not ensure its care or proper documentation, and the device was not cleaned according to manufacturer guidelines. For another resident, the oxygen nasal cannula was found on the floor while the oxygen concentrator was running, indicating improper administration and storage of oxygen equipment. The facility's policy required that oxygen tubing not be placed on the floor and be kept in a bag when not in use, but this was not followed. Additionally, another resident was observed receiving oxygen at a higher flow rate than ordered by the physician, and staff were incorrectly documenting compliance with the physician's order in the system. There was also a failure to post required oxygen signage on the door for a resident receiving oxygen therapy, as required by facility policy. These deficiencies were identified through observations, interviews with staff and residents, and review of medical records and facility policies. The failures included lack of physician orders, care plans, proper documentation, adherence to prescribed oxygen flow rates, and compliance with infection control and safety protocols for respiratory equipment.