Failure to Provide Safe and Appropriate Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care services for multiple residents, as evidenced by observations, interviews, and medical record reviews. For one resident, oxygen was not administered per the physician's order, the oxygen concentrator was not functioning properly, and the nasal cannula was neither dated nor changed weekly as required. Additionally, oxygen saturation was not consistently monitored or documented, and the oxygen concentrator was found to be incapable of delivering the ordered flow rate, necessitating replacement. Other deficiencies included failure to label and date respiratory equipment such as nasal cannulas, oxygen tubing, nebulizer bags, and prefilled humidifier bottles for several residents. In one case, a resident's Yankauer suction set-up bag was not dated or labeled, and the suction bacterial filter for another resident was not changed monthly as ordered. There were also instances where respiratory supplies were not changed according to facility policy or physician orders, and documentation of respiratory interventions was lacking in the medical records. Furthermore, one resident was administered oxygen therapy without a physician's order, and the equipment used was not labeled or dated. Staff interviews confirmed a lack of adherence to protocols regarding the changing, labeling, and dating of respiratory care equipment. The Director of Nursing and other staff acknowledged these findings during interviews, confirming that the facility's policies and physician orders were not consistently followed for respiratory care and infection control.