Failure to provide ordered oxygen therapy and care plan guidance for a resident with severe cognitive impairment, hospice services, and diagnoses including alcohol-induced dementia and Wernicke's encephalopathy. The resident had an order for 2 L O2 while resting in bed to prevent hypoxia and maintain O2 saturation above 90%, but was observed in bed without oxygen. RN verified the resident was not receiving O2, and the care plan did not include oxygen goals or interventions.
A resident with OSA, COPD, morbid obesity, and asthma had a physician order for CPAP at night, but she reported she had been unable to use it for about a month because the mask was missing. Surveyors observed the CPAP machine without a mask, and an LPN, NP, DON, and NHA all stated staff should have ensured the resident had a mask so she could use her ordered CPAP.
A resident with obstructive sleep apnea and asthma did not receive BiPAP as ordered. Staff observed the resident sitting in a recliner with eyes closed and snoring while the BiPAP was on the nightstand and not in use. A CNA said the BiPAP was only used at night, and an RN said it was used when the resident was in bed sleeping, despite the order stating it should be on whenever the resident was sleeping. The DON stated the BiPAP should be on if the resident was sleeping.
A resident with chronic respiratory failure and OSA had BiPAP orders requiring 3L O2 bleed-in, but CNAs and Med Techs were routinely applying the device without facility training or competency validation. Surveyors found staff using incorrect setup, including a nasal cannula under the mask instead of oxygen connected to the BiPAP, and the DON confirmed the facility had no CNA BiPAP competencies. The resident had episodes of respiratory decline, including being found unresponsive after a missed BiPAP session and later turning blue/gray with low O2 saturation when the BiPAP oxygen was not connected, leading to hospital transfers for acute respiratory failure and suspected aspiration.
Failure to Complete Required Pre- and Post-Nebulizer Assessments: An RN administered a nebulizer treatment to a resident with asthma and chronic respiratory failure but did not complete the required post-treatment respiratory assessment, and the surveyor did not observe the pre-treatment assessment being performed. The resident’s order required complete pre and post assessments, including lung sounds, RR, pulse, and O2 sat, and the DON stated RNs were expected to complete lung assessments within 15 minutes before and after nebulizer treatment.
Two residents receiving oxygen therapy with humidification had distilled water bottles that did not meet facility policy. One bottle was left uncovered and was dated beyond the 72-hour limit, while the other was open but not dated when opened. The residents had diagnoses including heart failure, pneumonia, and chronic pulmonary disease, and the DON verified the issues during observation.
Oxygen tubing/nasal cannula care was not ensured for one resident with acute and chronic respiratory failure, cor pulmonale, and COPD. Staff observed the resident using oxygen with no date label on the cannula/tubing, and RNs and the DON stated monthly changes are expected but could not verify when the tubing was last changed because it was unlabeled and not clearly documented.
A resident with COPD and other respiratory and cardiac diagnoses had an oxygen order for 1-2 L/min via NC, but surveyors repeatedly found the concentrator set at 3.5 L/min and left on when not in use. The resident’s care plan did not identify COPD, and staff interviews confirmed the flow rate should have matched the physician’s order and that COPD should have been reflected in the care plan.
A resident with cerebral palsy, quadriplegia, chronic respiratory failure, and severe cognitive impairment had a physician order for Cough Assist BID and PRN, but the order was not entered into the TAR and the treatment was not consistently provided in the facility. Staff interviews showed confusion about whether the order existed, and the DON could not find evidence it was provided. The resident was hospitalized multiple times for respiratory distress, aspiration, pneumonia, and sepsis, and hospital records noted use of Cough Assist during those stays.
Failure to Provide Ordered Respiratory Care: Two residents did not receive needed respiratory services. One resident on continuous O2 had tubing for the room concentrator that was not changed as ordered, while another resident with OSA wanted to use a CPAP machine but the machine was unplugged, parts were stored in a bag, and staff had not obtained an order or assisted with setup. The DON confirmed oxygen tubing should be changed weekly and that CPAP use should be ordered and care planned.
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