A resident receiving supplemental O2 had the nasal cannula in place while the tubing connector repeatedly remained on the floor and disconnected from the concentrator during multiple observations. CNAs and an LPN observed the resident in this condition, and the resident’s O2 sat was checked at 89% during the event. The resident had an order for O2 to keep sats above 90%, and the care plan called for O2 sat monitoring every shift and PRN when O2 was in use.
Respiratory equipment was not maintained for a resident with sleep apnea who used oxygen nightly. Surveyors observed visible debris buildup on the oxygen concentrator filter on multiple occasions, and the resident’s order required weekly tubing changes and regular filter cleaning. An LPN stated she had not been shown how to clean the filter, and the DON said the LPN had not yet been shown how to clean the oxygen concentrator.
Failure to Follow Oxygen Order: A resident receiving O2 had a physician order for continuous oxygen at 2 L/min via NC, but surveyors observed the concentrator set above the ordered rate on multiple occasions and later observed the resident without O2 and the concentrator powered off. The resident stated staff provide the tubing and adjust the concentrator, while the DON said the resident often removes the O2 and that the record did not reflect the frequent removal in progress notes or the care plan.
Unclean and improperly stored oxygen tubing was observed for two residents receiving O2. One resident’s tubing was left unbagged on top of the concentrator, while another resident’s unbagged tubing was connected to a portable tank on a wheelchair with the prongs touching the seat cushion and additional tubing tucked under the blankets. Records lacked evidence that tubing was changed weekly or that the concentrator filter was cleaned, despite facility policy requiring weekly cleaning and storage in plastic bags when not in use.
Respiratory care and the oxygen care plan were not followed for a resident with COPD. Staff observed the resident receiving O2 by NC at 1.5 LPM even though the current provider order was for 2 LPM continuously for SOB, and the resident was unsure of the correct setting. The care plan still listed oxygen as PRN at 1-2 L to keep O2 sat at or above 90%, and the RN and Regional Director confirmed the plan had not been updated to match the current order.
Failure to provide ordered respiratory care for two residents. One resident was observed in the dining room wearing nasal cannula tubing connected to an empty O2 tank, and an RN confirmed the tank was empty even though the resident was ordered continuous O2. Another resident had orders for continuous O2 up to 5 LPM and PRN albuterol for dyspnea, but the record showed O2 was given at 8 LPM without evidence of new orders, PRN neb treatments, or provider notification.
Improper Storage of Respiratory Equipment: The facility failed to maintain sanitary respiratory care equipment for 3 residents. A resident’s oxygen tubing was found on the floor, and two other residents had nebulizer tubing and masks left unbagged and exposed on a bedside table and shelf. The DON confirmed two of the findings, and an LPN confirmed the third. Facility policy required unused nasal cannulas to be bagged and nebulizer parts to be rinsed, air dried, and stored in a respiratory set up bag.
Respiratory equipment was not handled or documented according to orders. A resident on continuous O2 had unbagged, undated NC tubing stored with the prongs touching a wheelchair, floor, and concentrator, and staff placed the cannula back in use after it had contacted the floor while the O2 flow was set outside the ordered range. Another resident’s nebulizer tubing and mouthpiece were stored on the bed and lacked evidence of daily disinfection and proper storage. A third resident’s O2 equipment remained in place after O2 was discontinued, and another resident wore O2 without a current provider order or documentation of O2 amount and sat monitoring.
Failure to maintain sanitary respiratory equipment for two residents receiving O2 therapy. One resident had multiple nasal cannulas in the room, including unlabeled tubing on a wheelchair and oxygen cylinder caddy, and the resident stated the tubing on the face had not been changed as labeled. Another resident was observed with O2 tubing dated weeks earlier, while the charge nurse said tubing was believed to be changed weekly. Records showed weekly tubing changes were ordered, but documentation was incomplete and did not match the observations or the facility policy.
Unsanitary oxygen equipment and tubing storage: Two residents receiving O2 via nasal cannula were observed with dirty concentrators, including dust, dirt, and debris buildup on the machines and filter. One resident’s record had an order for weekly tubing changes but no evidence the filter was cleaned regularly. The DON stated there was no process for storing nasal cannulas or tubing when not in use, and tubing was being rolled up or hung on the concentrator without a bag.
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