A resident with COPD, CHF, severely impaired cognition, and oxygen dependence had physician orders for continuous oxygen at 0–4 L to maintain O2 saturation above 92%, with monitoring each shift and care plan directives to monitor oxygen and portable tank levels. Although the MAR showed continuous oxygen use and documented saturations, a visitor reported multiple occasions where the resident used empty portable tanks, and unused tanks were often empty. On one observation, the resident was found in bed with the nasal cannula off, the concentrator powered down, and tubing placed out of reach; staff, including a NA, an LPN, and the DON, all stated the oxygen should have been on and could not explain why it was off. The LPN documented that the resident’s O2 saturation was 90% before oxygen was reapplied, contrary to the physician’s order and facility policy requiring oxygen to be administered as ordered.
A resident with COPD, respiratory failure, emphysema, and pneumonia was ordered continuous O2 at 2 L/min via nasal cannula, but surveyors observed the oxygen concentrator set at 3 L/min on two occasions. The concentrator was out of the resident’s reach, and an RN later confirmed the setting was incorrect and adjusted it. The charge nurse stated she signed the TAR without checking the setting and assumed it was correct from the prior shift.
Ventilator and suction equipment were not consistently changed per facility policy for residents with trachs and ventilators. Two residents had ventilator circuit tubing dated from an earlier month, and one resident’s suction canister was still dated from the prior month despite orders for weekly suction equipment changes. RT and the DON of Respiratory stated ventilator circuit components and suction equipment were to be changed on a regular schedule, but the observed equipment did not match those expectations.
A resident with sleep apnea went without a properly fitting BiPAP mask for about 2 weeks because the equipment was not ordered in a timely manner, and staff reported confusion about who was responsible for ordering it. Another resident with a history of sleep apnea had oxygen tubing left in place far beyond the ordered weekly change schedule, and an LPN was unsure who was responsible for the task.
A resident with asthma, OSA, and oxygen therapy needs had respiratory distress and was placed on a non-rebreather mask at 5 L/minute, even though an LPN acknowledged that the device required a higher flow and APRN was not told the resident was on the mask. In a separate event, staff also set the resident’s NC oxygen above the written order of 2 L/minute, with an LPN increasing it to 4 L/minute based on report rather than the order.
A resident dependent on supplemental oxygen experienced acute respiratory distress and death after staff failed to assess, monitor, and report the resident's worsening condition, did not ensure the availability of functioning oxygen equipment, and did not communicate critical changes to supervisors or providers. Multiple staff members did not follow facility policies for change of condition and oxygen management, resulting in Immediate Jeopardy.
Failure to replace a resident’s nebulizer mask and tubing per policy. A resident with COPD, HF, and anemia had nebulizer equipment dated weeks earlier and observed stored uncovered and exposed in the room. An LPN acknowledged the tubing should have been replaced weekly and that the equipment was not in a storage bag as required by policy.
Missing oxygen order and undated tubing: A resident with altered respiratory status, hypoxemia, heart disease, CKD, and HF was observed using O2 at 2 L via NC, but the tubing was not dated when changed. Staff stated the resident used oxygen when short of breath even though there was no physician order for oxygen at the time, and the DON confirmed tubing should be changed and dated weekly.
A resident with obstructive sleep apnea was using a CPAP machine, but the facility failed to ensure that the physician's order included the required machine settings as specified by facility policy. The order only indicated the times for use, and staff could not explain the omission of the settings.
Failure to Maintain Ordered Oxygen Therapy: A resident with COPD and continuous O2 needs was found without nasal cannula oxygen in place, with the tubing disconnected and out of reach, while the concentrator was set at 2 L instead of the ordered 1 L. An RN stated she had not known the oxygen was off and later admitted she set the concentrator incorrectly. When oxygen was restored, the resident’s room air O2 sat was 82% and improved after O2 was reapplied.
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