Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards for a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure, and dementia. The resident required continuous oxygen therapy via nasal cannula at a prescribed flow rate, as well as regular monitoring of peripheral oxygen saturation (spO2) every shift, per physician orders. The care plan also specified returning the resident to their usual oxygen delivery method after meals and administering medications as ordered. During an observation, the resident was found lying in bed with the nasal cannula disconnected and wrapped around the oxygen concentrator, which was turned off. A Licensed Vocational Nurse (LVN) confirmed that the resident was not connected to oxygen and stated that staff should have ensured the oxygen was properly administered after providing care. A Registered Nurse (RN) also acknowledged that staff failed to administer oxygen as ordered, which could result in low oxygen levels and respiratory decline for the resident. Record review revealed that the Medication Administration Record (MAR) lacked staff initials for several shifts, indicating that both oxygen administration and spO2 monitoring were not documented as completed on multiple occasions. Facility policies required staff to check oxygen equipment for proper function and to administer medications, including oxygen, as prescribed and in a timely manner. These actions and omissions led to the deficiency in providing safe and appropriate respiratory care for the resident.