Failure to Provide Safe and Appropriate Respiratory Care per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician orders and accepted professional standards for four out of five residents reviewed for respiratory services. For one resident with chronic hypoxic respiratory failure and COPD, there were multiple inconsistencies in oxygen administration, including titrating oxygen below the ordered rate, not documenting the actual flow rate delivered, and delays in providing prescribed respiratory equipment such as CPAP and BiPAP machines. Documentation showed that staff did not consistently follow or document the specific oxygen flow rates as ordered, and there were periods when the resident did not have access to required respiratory equipment, resulting in repeated hospitalizations for respiratory complications. Another resident with COPD was observed receiving oxygen at a rate that was not documented in the medical record, and staff failed to record the oxygen flow rate or corresponding oxygen saturation as required by physician orders. Orders for changing nasal cannulas and oxygen tubing were inconsistently documented, and staff interviews confirmed that documentation practices did not align with facility policy or physician directives. Additionally, there was confusion among staff regarding the necessity and frequency of changing respiratory equipment, with some orders being redundant or unclear. For two other residents with COPD, observations revealed improper use of humidification with oxygen therapy, lack of documentation regarding whether oxygen saturation was measured with or without supplemental oxygen, and discrepancies between observed oxygen flow rates and those ordered by the provider. Staff interviews further revealed a lack of clarity and consistency in following and documenting respiratory care orders, including the administration of oxygen at the correct flow rates and the timely replacement of respiratory equipment such as humidifier bottles and tubing.