Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for two residents. For one resident with diagnoses including acute respiratory failure with hypoxia and hypercapnia, the facility failed to ensure there was a current physician's order for oxygen therapy. Despite the resident being observed on supplemental oxygen via nasal cannula at a specified flow rate, a review of both electronic and paper health records did not reveal an active physician's order for oxygen therapy. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that orders should be documented in the electronic health record, but no such order was present at the time of review. Facility policy requires a physician order for the admission of oxygen, which was not followed in this case. For another resident with chronic obstructive pulmonary disease, asthma, and respiratory failure, the facility failed to ensure that licensed staff appropriately evaluated the resident's oxygen therapy during a potentially urgent medical situation. The resident, who was dependent for bed mobility and transferring and was receiving oxygen therapy and non-invasive mechanical ventilation, was observed experiencing significant shortness of breath and calling for help. The LPN who responded did not initially assess the resident's oxygen therapy, instead attempting to adjust the room's air conditioner and fan. The resident's oxygen was later found to be disconnected from the concentrator, and only after intervention by another staff member was it reconnected. The LPN returned with a pulse oximeter and found the resident's oxygen saturation to be below the target level. Additionally, the facility's policy and procedure manual for oxygen administration did not include evaluation criteria for residents experiencing shortness of breath while receiving oxygen therapy. This lack of clear guidance contributed to the failure to provide appropriate and timely evaluation and intervention for the resident in respiratory distress.