Failure to provide ordered oxygen therapy for two residents. One resident with a tracheostomy was observed with the oxygen concentrator turned off, so the resident was not receiving the ordered O2 via tracheal collar, and the tracheal collar and tubing were not dated. Another resident with hypoxia and OSA had O2 via NC in use, but the tubing date did not match the weekly change schedule, and RN confirmed the facility’s tubing-change process was not followed.
Improperly Secured Oxygen Cannister Holder: A resident with diagnoses including DM2, stroke, neurogenic bladder, and vascular dementia had an order for O2 at 2 LPM PRN for SOB. Surveyors observed the oxygen tank in a four-point cannister holder strapped incorrectly to the back of the wheelchair, with all straps shifted to one side and a tear in the bottom of the holder. The UM stated the oxygen had recently been changed to PRN and did not know why it was on and operating all day; the DON confirmed the holder was not positioned correctly and was torn.
A facility failed to follow physician orders for oxygen administration and did not have oxygen storage bags present for two residents receiving oxygen. One resident with COPD and other respiratory diagnoses was observed receiving less oxygen than ordered, and an LPN confirmed the ordered flow rate was not being followed and that no storage bag was present. Another resident with acute respiratory failure with hypoxia and severe cognitive impairment was also observed receiving less oxygen than ordered, with an LPN confirming the discrepancy and the absence of a storage bag. The DON confirmed that oxygen orders should be followed and that storage bags should be present.
Failure to Follow Physician Orders for Oxygen Therapy: Two residents with respiratory diagnoses had ordered continuous oxygen therapy, but staff did not maintain the prescribed flow rates. One resident was observed at 3 L/min instead of 4 L/min and later without oxygen when a CNA removed the tubing and turned off the concentrator. Another resident’s oxygen was observed at 2 to 2.5 L/min instead of the ordered 3 L/min, and an LPN confirmed the incorrect settings.
Respiratory equipment was not maintained in a sanitary manner and there were no physician orders for oxygen equipment maintenance for a resident receiving O2. The resident had severe cognitive decline, respiratory failure, and other significant diagnoses, and was observed receiving oxygen with a visibly dusty tank, undated tubing, and a nebulizer mask not stored in a bag or dated. The DON and Administrator acknowledged staff were expected to clean the oxygen tank and change tubing and water bottles weekly, but no orders or tracking documentation were provided.
Failure to maintain and service oxygen concentrators: The facility did not clean an oxygen concentrator filter weekly for a resident with COPD, dementia, sleep apnea, and continuous O2 therapy, and the filter was observed covered with dirt and lint on multiple occasions. Staff said night shift was responsible for cleaning the concentrators, but there was no documentation that the filter was cleaned. The facility also could not provide records showing preventative maintenance or servicing for two DeVilbiss concentrators, and leadership gave conflicting information about who was responsible for the equipment.
The facility failed to store oxygen tubing, NCs, and masks in a sanitary manner for three residents, and one resident had no oxygen order. A resident with respiratory failure and CHF was observed with an uncovered NC in a plastic bag on the floor, another resident with COPD had oxygen tubing and an NC lying on the floor and later hanging off the bed without a plastic cover, and a third resident with chronic respiratory failure, COPD, and Alzheimer’s disease had oxygen tubing and an NC on a food tray and a nebulizer mask on the overbed table. Staff stated the NC should be stored in a plastic bag when not in use, and the DON stated tubing/NC/masks should always be stored in a clear plastic bag and not reused after being dropped on the floor.
Oxygen Not Administered as Ordered: A resident with COPD, CHF, and respiratory failure with hypoxia had a physician order for continuous O2 at 2 L/min via nasal cannula, but was observed receiving 1.5 L/min on multiple occasions. An RN confirmed the resident was not receiving the ordered rate, an LPN verified the MAR showed the 2 L/min order, and the DON stated she was aware of the discrepancy.
Uncovered nebulizer equipment was left on a resident’s nightstand, with the mask and tubing not labeled or dated to show when they were last replaced. The resident had pneumonia, moderate cognitive impairment, and an order for PRN nebulizer treatments, but MAR/TAR review showed no treatments had been given since admission. An LPN said the equipment was normally stored in a bag in the resident’s drawer, but the resident had removed it; the DON stated nebulizers, masks, and tubing are expected to be cleaned and stored properly.
A resident with acute respiratory failure with hypoxia had physician orders for oxygen at 3 LPM, later changed to 2 LPM, but was repeatedly observed on a concentrator set at 4.5 LPM. The care plan still referenced the older oxygen setting, and staff interviews showed an RN confirmed the ordered flow rate while an LPN believed oxygen could be titrated without an order; the DON stated oxygen orders were to be followed as written.
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