A resident with obstructive sleep apnea and shortness of breath had a C-PAP machine present in the room and reported using it for over 15 years, but the medical record did not include a physician order for C-PAP use. An LPN and the ADON both confirmed the missing order.
A resident with pneumonia, COPD, emphysema, OSA, sepsis, and dementia was discharged from the hospital with a BiPAP order, but the facility did not enter the order into the EMR or MAR and did not clarify the order when the resident’s personal CPAP machine was brought in. The DON and PA stated the order was not properly reconciled or clarified, and the resident was later transferred to the ER.
Respiratory care orders were not followed or entered for several residents. Multiple residents on O2 had nasal cannulas or tubing left unchanged beyond the ordered weekly schedule, a resident with a trach had no trach care orders until later in the stay, and another resident’s oxygen orders were missing from the chart and MAR even though staff documented and observed O2 use at varying flow rates. Nursing leadership acknowledged the missing or uncompleted orders.
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.
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