Failure to administer oxygen in accordance with the physician order occurred for a resident on continuous O2 therapy. The resident, who had an irregular heartbeat and intact cognition, was observed with portable O2 that was not delivering oxygen because the tank valve was not connected correctly; the resident was unaware the tank was not working, and the DON later found the O2 saturation was 91%. Staff reported that the CNA had set up the portable O2, while the RN stated nurses regulate and administer O2.
A resident with acute pulmonary edema, atrial fibrillation, pulmonary hypertension, and edema was admitted without oxygen therapy and had documented shortness of breath, abnormal lung sounds, and a productive cough, but no respiratory care focus was added to the care plan. Daily skilled assessments contained copied-forward oxygen saturation values and an incorrect COPD reference, and when the resident’s oxygen saturation declined, an LPN initiated continuous oxygen at 2 L/min without documented physician notification or an order. Despite worsening shortness of breath and documentation that the resident became oxygen dependent, staff only notified the practitioner about cellulitis and wound issues, and the resident was later sent to the ED by family, where EMS and ED records showed significant hypoxia and diagnoses including acute hypoxic respiratory failure.
A resident receiving CPAP therapy had no routine cleaning schedule for the CPAP equipment, and staff did not have current CPAP settings available. The resident reported the equipment had not been cleaned since admission and was unsure whether the settings were correct. Orders listed nightly CPAP use, but the settings were not documented, and the care plan did not include cleaning, maintenance, or setting instructions.
Failure to provide ordered supplemental oxygen for a resident with COPD and anemia. The resident had a care plan for continuous O2 via NC and a physician order for PRN O2 for SOB/comfort, but O2 sat documentation was absent after the last recorded check. Staff observed the resident on oxygen with the concentrator set at 2 L/NC, and later the resident was seen with NC tubing connected to an oxygen tank that was turned off. An LPN said he had not yet checked the resident’s oxygen or tubing, and the DON stated staff should have assessed the resident’s need for more than 1 L/NC and followed the order.
Failure to obtain BiPAP orders and accurate settings for a resident with pneumonia, sepsis, and OSA. The MDS and care plan did not reflect BiPAP use, yet the admission assessment documented BiPAP use and the resident was observed using the device in her room. The resident said staff only filled the water tank, while an RN stated BiPAP use should be supported by an order with documented care and on/off times; the ADON, Administrator, and RDCS said they were unaware the resident was using BiPAP.
Failure to order and clean CPAP equipment: A resident with obstructive sleep apnea used a CPAP mask at night, but the EHR had no physician order for CPAP use and no order for cleaning the CPAP machine or mask. The resident stated staff had not cleaned the CPAP equipment since admission, and staff interviews confirmed the missing orders and uncertainty about who was responsible for cleaning. The DON acknowledged the lack of CPAP and cleaning orders, while the facility policy required physician orders and routine cleaning of the device and mask.
Nebulizer tubing and mask were not changed for a resident with asthma and COPD who received scheduled and PRN nebulizer treatments. Staff observed tubing still dated from weeks earlier, and the ADON acknowledged it had not been changed since that date. The care plan addressed nightly cleaning, but the orders and TAR did not specify tubing or mask change frequency.
A resident with obstructive sleep apnea and moderate cognitive impairment used a CPAP machine that was observed to have visible sediment and discoloration on the device, reservoir, and mask, while the resident reported that staff had never cleaned the equipment since admission. Nursing staff, including RNs and an LPN, stated they believed the resident cleaned the CPAP herself, yet the care plan and TAR contained no documentation assigning this responsibility to the resident or ordering staff to perform the cleaning. The DON confirmed the lack of documentation despite facility policy requiring CPAP equipment to be cleaned, stored, and documented per manufacturer instructions and the Infection Prevention and Control Program.
Failure to administer oxygen per physician order. A resident with asthma, chronic lung disease, and oxygen therapy needs was ordered 2 L via n/c continuously, but staff observed the oxygen concentrator set at 0.5 L on two occasions. An LPN verified the incorrect setting and the resident stated the oxygen was supposed to be at 2 L. The DON confirmed the order and reported the facility did not have an oxygen therapy policy.
BiPAP Equipment Cleaning Schedule Not Established: A resident with OSA, respiratory failure, and obesity used a BiPAP at night, but staff had not established or followed a routine cleaning schedule for the tubing or facemask. The resident stated the equipment had never been cleaned, and the care plan and treatment record contained no cleaning or maintenance instructions. The DON confirmed the facility failed to initiate a cleaning schedule for the BiPAP equipment.
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