Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for two residents, resulting in deficiencies related to the administration and monitoring of oxygen and CPAP therapy. For one resident with chronic obstructive pulmonary disease and obstructive sleep apnea, physician orders for CPAP and continuous oxygen therapy were not entered until several days after admission. The care plan did not specify the type or amount of oxygen, nor did it include a plan for CPAP use. Staff interviews revealed that the resident required constant supplemental oxygen, and an incident occurred where the resident arrived at a community day center short of breath with a blood oxygen level of 80% due to a portable oxygen tank not being turned on and kinked tubing, resulting in the resident being without supplemental oxygen for at least 25 minutes. For another resident with heart failure, there was a discrepancy between the physician's order for oxygen and the transcription of that order to the treatment administration record (TAR), leading to uncertainty among staff regarding the correct oxygen setting. Additionally, the oxygen tubing was not changed according to the schedule indicated in the TAR, as the tubing observed in the resident's room was last changed over a week prior, despite documentation stating otherwise. Staff interviews confirmed a lack of clarity regarding the resident's oxygen settings and the required frequency for changing oxygen tubing.