A resident with CHF, CKD, and cardiomyopathy, and severe cognitive impairment, was observed receiving oxygen at 3 L/min by nasal cannula without a physician order. The chart showed no oxygen order during the review period, and an LPN confirmed the omission before an order was later obtained.
Failure to Follow Ordered Oxygen Rates: The facility failed to administer oxygen as ordered for three residents. One resident with acute respiratory failure was observed receiving oxygen at 2.5 to 3 L/min despite an order for 1 L/min continuous. A second resident with dementia, OSA, CHF, and atrial fibrillation was observed on 3 L/min even though the order was for 2 L/min PRN, and the MAR and care plan did not reflect the oxygen use. A third resident with dementia and emphysema was also observed on 3 L/min despite an order for 2 L/min continuous; an LPN and the DON confirmed the ordered rates.
Missing Physician Order for CPAP Use: A resident with obstructive sleep apnea had nursing notes documenting CPAP compliance, but the order recap did not include a physician order for CPAP use. An admitting LPN acknowledged missing the CPAP during the admission assessment, another LPN did not verify an order was present, and the DON confirmed the resident should have had an order for the CPAP machine.
A resident with respiratory failure, tracheostomy, and gastrostomy was observed without an ambu bag in the room despite facility policy requiring emergency respiratory supplies to be easily accessible for immediate care. The resident was severely cognitively impaired, dependent for all ADLs, and had orders for trach care, oral care, daily inner cannula changes, and suctioning as needed; both an LPN and the DON stated the ambu bag should be kept in the room near the bed.
Improper Storage of Respiratory Equipment: Respiratory equipment was found uncovered and open to air for four residents receiving oxygen or nebulizer treatments. A resident with COPD and respiratory failure, another resident with heart failure and asthma, a resident with dementia and heart disease, and a resident with COPD and dementia all had masks or tubing left out in their rooms instead of being stored in a bag when not in use, and the IP confirmed the equipment was not stored appropriately.
Soiled Nebulizer Circuit Left Improperly Stored: A resident with COPD and moderate cognitive impairment had a nebulizer circuit observed with dried residue between the corrugated rings, with the mouthpiece resting on the nightstand and part of an emesis bag lying across the tubing. Staff confirmed the circuit was not cleaned, covered, or stored appropriately, despite the resident’s nebulizer order and facility policy for clean, labeled, dated storage and weekly changes.
Missing Physician Orders for respiratory support and oxygen safety issues were identified for several residents. A resident dependent on a ventilator and two residents with tracheostomies were observed receiving respiratory support, but the chart lacked orders for ventilator use, settings, suctioning, and trach type or size as applicable. The facility also failed to follow oxygen orders for one resident and did not securely store portable oxygen tanks in two residents' rooms, despite policy requiring written orders and secured cylinder storage.
Respiratory Care Deficiencies With Oxygen Orders, Storage, and Flow Rate: A resident receiving O2 had no physician order in place for a period of time, no O2 warning sign posted, and tubing that was left uncovered and not stored in a bag when not in use; staff also could not confirm when the tubing had last been changed. Another resident’s nasal cannula was likewise left open to air without proper storage, and a third resident was observed receiving O2 at 3 L/min when the physician order was for 2 L/min. The DON confirmed the ordered flow rate was not being followed.
A resident with COPD and a tracheostomy was observed receiving trach care in the facility, but the chart lacked a physician order for self-care and had no documented assessment of the resident’s ability to change the inner cannula or perform trach care using sterile technique. An LPN and the resident stated he did his own trach care, another LPN agreed, and the DON confirmed the missing order and assessment; the physician said nursing was told to monitor the care and did not know an order had been written for self-care.
Failure to Follow Oxygen Order: A resident with COPD, chronic respiratory failure, and dependence on supplemental O2 had a physician order for 2 L via NC, but staff documentation and direct observations showed oxygen being administered at 2.5 L, 3 L, and 3.5 L on multiple occasions. The MAR reflected 2 L, while RT notes and staff interviews confirmed the resident was actually receiving higher flow rates than ordered.
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