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.
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.
Oxygen was not provided at the ordered rate for a resident with COPD, dysphagia, and Alzheimer’s disease. The resident’s order specified 2 L/min via NC continuously, but surveyors observed the concentrator running at 3 L/min while the resident was sleeping in bed on multiple occasions. An LPN acknowledged the oxygen was running above the ordered rate and stated the flow level was not checked during med pass, and the ADON confirmed staff needed to follow the physician’s order.
Respiratory Treatment Orders and Oxygen Delivery Not Followed: Two residents did not receive respiratory care consistent with physician orders. One resident’s CPAP order lacked settings and administration details, and the TAR had no documented CPAP administration despite ongoing references to CPAP use. Another resident ordered for O2 at 2 L/min was repeatedly observed receiving 3.5 L/min, and the LPN unit manager confirmed the ordered rate was not followed.
A resident with CHF, sepsis, cardiogenic shock, and severe cognitive impairment was ordered supplemental O2 via NC at 2 L/min, but surveyors observed the bedside concentrator delivering 3-4 L/min and then 4 L/min. The resident’s tubing was undated, and interviews with the NP, RN, and DON confirmed staff were responsible for verifying the ordered flow rate, dating/labelling tubing, and monitoring pulse ox, but the resident’s oxygen was not being provided as ordered.
A resident with CHF, chronic respiratory failure with hypoxia, and pleural effusion was receiving continuous oxygen at 4 L/min by NC, but the portable oxygen tank was repeatedly found in the red empty zone during observations. The resident was seen with a non-productive cough, and an LPN replaced the tank only after the surveyor asked her to check it. The care plan called for monitoring for respiratory distress, and the facility policy required checking oxygen equipment and observing tolerance.
Oxygen was administered to a resident without a valid physician order. The resident had lung cancer, PE, and acute respiratory failure, and was receiving oxygen via NC after returning from the hospital. Surveyors observed the NC on the floor and later found the concentrator set at 0 L/min, while the EHR contained no order for oxygen during the period reviewed. An LPN could not locate an order, and the MD later stated there had been no previous order even though oxygen had been continued.
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