A resident who required oxygen therapy for SOB had an oxygen bubbler that was overdue for replacement, despite a TAR directing weekly changes of oxygen supplies including the bubbler and tubing. Staff confirmed the bubbler should have been changed weekly, and the DON and staff educator stated nurses were expected to follow the provider order as written and that all disposable oxygen pieces were to be changed weekly.
Hygienic care of oxygen and nebulizer equipment was not maintained for a resident with CHF, COPD, a-fib, Parkinsons, and other significant diagnoses. The resident’s oxygen setup included a water bubbler dated months earlier, and the nebulizer mask, chamber, and tubing were left connected at the bedside with liquid and later condensation in the chamber. The resident said he used the nebulizer himself and that staff sometimes did not return to clean it, while an RN said the nebulizer should be cleaned after every use and an LPN confirmed the bubbler and tubing were not being changed as ordered or dated per policy.
Incomplete respiratory orders and oxygen not provided as ordered. The facility failed to ensure complete trach and O2 orders for two residents with trachs and respiratory conditions. One resident’s O2 was repeatedly set at 3 LPM instead of the ordered 5 LPM, and another resident received O2 without a current order for flow rate, delivery method, frequency, or parameters. The trach care orders for two residents did not identify the specific trach type or size, and RN-A, the RNCM, and the DON confirmed the missing order details.
A resident with COPD, chronic respiratory failure with hypoxia, and other serious cardiopulmonary diagnoses developed respiratory distress during care, with O2 saturation falling from 84% on 2 L/min to 74% on 3 L/min. Although orders and standing orders allowed oxygen titration and required immediate provider notification for SOB or other respiratory concerns, an LPN left the resident, did not obtain full vital signs, did not reassess after interventions, and did not notify the provider. Family members reported the resident was cyanotic and unable to speak, and the provider call log showed no notification.
Oxygen tubing and humidifier maintenance was not properly documented for a resident with severe cognitive impairment and multiple cardiac and respiratory diagnoses. The resident had an order for O2 2 L PRN, but the TAR lacked instructions for cleaning, maintenance, or changing tubing across multiple months, and observation found undated tubing hanging to the floor with an undated, partially filled humidifier attached. Nursing leadership stated tubing and humidifiers were to be changed weekly and dated, and the DON and ADON expressed concern for infection risk.
A resident with COPD, OSA, atrial fibrillation, and heart failure had conflicting oxygen orders in the chart, with hospital discharge paperwork showing 2 L/min at bedtime while facility records reflected 6 L continuous oxygen without a signed physician order. After a room change, the oxygen concentrator was left in the old room, and the resident’s portable tank ran empty overnight because staff did not have a consistent process for checking tank levels. The resident was found unresponsive on the toilet with no oxygen available.
A facility failed to include resident-specific CPAP/BiPAP settings in the orders for two residents using non-invasive ventilation, even though staff were assisting with mask placement and machine use and the records lacked documented pressure settings. The facility also failed to reinstate oxygen-related orders after a resident returned from the hospital; the MAR/TAR had no active oxygen or saturation-monitoring orders, while staff still described the resident as needing oxygen at 2 LPM and oxygen tubing was observed on the floor with the tank left on.
A resident with intact cognition and a history of MS had a BiPAP machine at bedside, but the chart lacked resident-specific BiPAP orders, settings, and documentation of staff assistance, mask cleaning, or tubing/filter changes. Staff and the DON confirmed the resident used BiPAP and received help with the mask and machine, while the MAR, task log, care plan, and progress notes did not reflect that care.
Incomplete BIPAP Orders and Missing Respiratory Settings Documentation: A resident with intact cognition and use of a non-invasive ventilator had BIPAP orders for bedtime use, daily water changes, and weekly cleaning, but the orders did not include specific settings or clear direction to verify or maintain them. Staff stated BIPAP units were typically pre-set by a respiratory company and nurses checked them, but the resident’s record lacked documentation of the respiratory company setup and the specific BIPAP settings.
A resident with significant cardiopulmonary conditions and an NP order for continuous O2 at 2 L/min to maintain SpO2 >90% was sent to an off-site wound care appointment without supplemental O2. Nursing documentation showed recent low-normal SpO2 readings on 1–2.5 L O2, and a progress note recorded SpO2 of 93% on 1 L O2 before departure. A CNA, who was unaware the O2 order had been changed to continuous and reported issues with a hissing portable tank and resident refusal while getting ready, assisted the resident and allowed her to leave without O2. At the clinic, the resident was found lethargic with SpO2 of 70% on room air and was transferred to the ED, where she was documented as hypoxic, tachycardic, and experiencing acute on chronic respiratory failure, with hospital notes indicating that lack of O2 may have precipitated the event.
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