A resident using CPAP had no physician order for the device or its settings, and the CPAP mask and tubing were observed left uncovered on the bedside table instead of stored in a bag. Three oxygen-dependent residents were repeatedly observed with concentrator filters covered in thick dust while staff were unsure who was responsible for filter cleaning, and the records lacked orders for filter maintenance.
Failure to Document and Administer Ordered Oxygen Therapy: A resident with COPD and oxygen dependence had incomplete O2 orders that did not include a baseline flow rate or portable flow rate, and MAR/TAR documentation did not show the oxygen flow rate being administered. Surveyors observed the resident in a wheelchair with NC tubing not connected to the portable concentrator, and staff later confirmed the resident used O2 at 2 LPM and that a respiratory assessment should have been documented when oxygen was given.
A resident with respiratory failure, pneumonia, and severe cognitive impairment was observed multiple times receiving O2 via NC at 2.5 L/min even though the physician ordered 2 L/min to keep saturation above 90%. The resident’s oxygen controls were out of reach, and the chart did not show any order, note, or low O2 sat reading to justify the higher rate. The nurse, unit manager, and DON all stated oxygen should be given per the physician’s order.
Oxygen therapy and nebulizer equipment were not managed as ordered for two residents. One resident with pulmonary fibrosis, pneumonia, and acute respiratory failure with hypoxia was observed receiving O2 above the ordered 2 L/min, and another resident with chronic respiratory failure with hypoxia was also observed on 3 L/min instead of 2 L/min. For the second resident, nebulizer tubing was undated and the mask was stored outside the respiratory bag, contrary to staff-described infection control practices and the resident’s orders.
Failure to Follow Oxygen Order: A resident with dementia, depression, and acute respiratory failure with hypoxia was observed multiple times receiving O2 via NC at 3 L/min, while the physician's order directed 2 L/min continuous and 2 L/min PRN for O2 sats below 90% on room air. The care plan referenced oxygen use, and nursing notes also documented the resident on 3 L/min. Staff interviews confirmed that oxygen should be given per the MD order.
A resident with OSA, COPD, CHF, chronic respiratory failure with hypoxia, and morbid obesity did not receive the recommended BiPAP machine. Pulmonology records noted the resident had not been using BiPAP because of missing parts, later provided only a full-face mask, and reported that the nursing home had taken away the BiPAP device. Facility staff did not clarify the consultant report or follow up on the BiPAP equipment, and the resident stated only a mask was in the room with no CPAP or BiPAP machine.
Dirty Oxygen Concentrator Not Maintained: A resident receiving oxygen via NC had an oxygen concentrator cabinet with dried white and brown debris and filters coated in thick gray dust. Staff said the cabinet and filters should be cleaned weekly, but the unit remained unchanged on repeat observation, and the IP and DON were unsure of the facility’s cleaning schedule for oxygen concentrators.
Failure to Provide Ordered Oxygen to Two Residents: Two residents with COPD and severe cognitive impairment were observed with empty portable O2 tanks while wearing nasal cannulas, and staff did not ensure oxygen was being delivered at the ordered rate. One resident’s O2 sat was documented at 85%, then 74% and 80% on repeat checks; the other resident’s O2 sat was 74% and later 80%. The nurse stated he had not assessed the residents’ oxygen needs that day, and the CNA said tank checks were the nurse’s responsibility.
A resident with COPD, heart disease, and HTN did not receive O2 at the ordered 2 L/min via NC PRN. Surveyors repeatedly observed the concentrator set at 3.5 L/min, while the resident stated he/she did not adjust the dial and an LPN confirmed the O2 was supposed to be set at 2 L/min. The care plan and progress notes did not indicate that the resident self-adjusted the flow rate.
Oxygen Therapy Not Provided per Physician Orders: Two residents had respiratory care that did not match ordered treatment. One resident with emphysema and COPD was observed receiving O2 by NC at 1 L/min even though the chart lacked a physician order for oxygen or saturation checks after a hospital return. Another resident with COPD, asthma, and severe cognitive impairment was observed on multiple occasions receiving O2 at 4 L/min despite an order to titrate only 0-2 L/min to keep SpO2 above 89%, and was also found without O2 at times with the concentrator off or out of reach. Nursing documentation showed oxygen was charted above the ordered flow rate on multiple shifts.
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