A resident using BiPAP had no documented physician order or care plan for the therapy, and the mask was repeatedly observed with white debris inside. The resident said staff never cleaned the tubing or mask, while an LPN and unit manager noted that BiPAP use should have had an order, care plan, settings, and daily cleaning documentation.
A resident with COPD and oxygen use orders was observed receiving oxygen with tubing dated beyond the weekly change schedule. Staff stated the tubing should be changed weekly on Sundays for infection control, but it had not been changed as expected, and the DON noted the order should have been a standing order rather than PRN.
Oxygen Flow Rates Exceeded Physician Orders: Two residents received oxygen at settings above the physician order. One resident with CKD, cirrhosis, and acute respiratory failure had an order for 3 L/min PRN, but the concentrator was observed at 3.75 to 4 L/min. Another resident with MS, dementia, and respiratory failure had an order for 2 L/min continuous, but the concentrator was observed at 2.5 L/min and between 2 and 3 L/min. An LPN confirmed the incorrect settings, and the DON stated nurses were expected to set oxygen flow rates per orders.
Two residents with tracheostomy or laryngectomy tubes did not receive respiratory care in accordance with facility policy and professional standards. One resident with throat cancer and HIV reported not receiving trach care or suctioning despite documented orders, while surveyors observed uncovered and soiled suction equipment, undated respiratory supplies, and no Ambu bag at the bedside; an LPN could not locate needed trach supplies, described care as merely wiping the stoma, and admitted most nurses needed a skills refresher. Another resident with an artificial airway and cirrhosis had care plan interventions for respiratory monitoring and suctioning, but the health care proxy expressed concerns about staff competency to manage the airway and could not confirm the presence of emergency airway equipment. Interviews with the DON, an RN, and the Medical Director confirmed that clean, dated supplies, complete trach care, and an Ambu bag at bedside were expected, yet these standards were not consistently met.
Failure to provide appropriate CPAP respiratory care for a resident with OSA, COPD, and a history of headaches. The resident’s CPAP, tubing, and mask were observed open to air at the bedside, the resident said they needed help turning it on and had not used it for two weeks because it needed cleaning, and the chart lacked a CPAP order, settings, and a care plan intervention for CPAP. Staff stated they did not act on the device because it was the resident’s own machine or because no order was present, and the MD was unaware the resident had gone without CPAP use.
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with chronic atrial fibrillation, CHF, heart failure, and severe cognitive impairment was ordered oxygen at 2 L/min via NC PRN for SOB, but was observed receiving 3 L/min on multiple occasions. An LPN stated nursing staff on all shifts were responsible for calibrating oxygen and confirmed it should have been set at the ordered 2 L/min.
Incorrect Oxygen Flow Rate and Missing O2 Monitoring: A resident with severe cognitive impairment and orders for O2 via NC at 2 L/min was observed receiving 4 L/min instead. The chart lacked O2 saturation documentation even though the order called for monitoring every shift. Staff interviews showed the LPN did not know who changed the flow rate, the CNA was not trained to adjust or monitor O2, and the DON acknowledged there was no O2 sat order in place.
BiPAP Care, Cleaning, and Documentation Not Maintained: A resident with respiratory failure and OSA was ordered constant oxygen with BiPAP, but staff did not consistently document BiPAP use, settings, water checks, or respiratory assessments. The BiPAP reservoir was found empty at times, the mask had dried debris and was not being cleaned, and staff were unsure of the resident’s BiPAP orders, oxygen bleed-in directions, and who was responsible for cleaning and monitoring the equipment.
A resident with chronic kidney disease on dialysis, cellulitis, and metastatic endometrial cancer received intermittent O2 therapy without a physician’s order or related care plan interventions, contrary to facility policy requiring a specific medical order and respiratory care plan. MAR and vital sign records documented the resident on 2L O2 on multiple occasions, including pre-dialysis, and staff reported the resident returning from dialysis on portable O2, being supplied with O2 tanks for trips, and having O2 in place at the time of death. The Administrator acknowledged that an O2 order should have been in place.
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