A resident with COPD, CHF, severely impaired cognition, and oxygen dependence had physician orders for continuous oxygen at 0–4 L to maintain O2 saturation above 92%, with monitoring each shift and care plan directives to monitor oxygen and portable tank levels. Although the MAR showed continuous oxygen use and documented saturations, a visitor reported multiple occasions where the resident used empty portable tanks, and unused tanks were often empty. On one observation, the resident was found in bed with the nasal cannula off, the concentrator powered down, and tubing placed out of reach; staff, including a NA, an LPN, and the DON, all stated the oxygen should have been on and could not explain why it was off. The LPN documented that the resident’s O2 saturation was 90% before oxygen was reapplied, contrary to the physician’s order and facility policy requiring oxygen to be administered as ordered.
A resident with COPD, respiratory failure, emphysema, and pneumonia was ordered continuous O2 at 2 L/min via nasal cannula, but surveyors observed the oxygen concentrator set at 3 L/min on two occasions. The concentrator was out of the resident’s reach, and an RN later confirmed the setting was incorrect and adjusted it. The charge nurse stated she signed the TAR without checking the setting and assumed it was correct from the prior shift.
Ventilator and suction equipment were not consistently changed per facility policy for residents with trachs and ventilators. Two residents had ventilator circuit tubing dated from an earlier month, and one resident’s suction canister was still dated from the prior month despite orders for weekly suction equipment changes. RT and the DON of Respiratory stated ventilator circuit components and suction equipment were to be changed on a regular schedule, but the observed equipment did not match those expectations.
A resident dependent on supplemental oxygen experienced acute respiratory distress and death after staff failed to assess, monitor, and report the resident's worsening condition, did not ensure the availability of functioning oxygen equipment, and did not communicate critical changes to supervisors or providers. Multiple staff members did not follow facility policies for change of condition and oxygen management, resulting in Immediate Jeopardy.
A resident with obstructive sleep apnea was using a CPAP machine, but the facility failed to ensure that the physician's order included the required machine settings as specified by facility policy. The order only indicated the times for use, and staff could not explain the omission of the settings.
Two residents with respiratory conditions did not receive safe and appropriate respiratory care. One resident was administered supplemental oxygen without a current physician's order, despite facility policy requiring such orders. Another resident experiencing acute shortness of breath was not properly evaluated by an LPN, who failed to assess the resident's oxygen therapy and did not recognize that the oxygen supply was disconnected. The facility's oxygen administration policy lacked criteria for evaluating residents in respiratory distress.
A resident with a history of acute respiratory failure and pneumonia had a standing order for continuous oxygen, but was observed multiple times without oxygen in use and confirmed not receiving it. The care plan lacked respiratory interventions, and staff interviews revealed the resident had been titrated off oxygen without updating the physician's order. Nursing staff and the DNS acknowledged the lapse in ensuring orders were current and accurately implemented.
A resident with chronic respiratory conditions was administered continuous oxygen therapy by licensed staff without a physician's order for eight days. Documentation showed the resident received varying oxygen flow rates, and the required order was only obtained after the DON identified the omission during a record review, in violation of facility policy.
Two residents with complex medical needs did not receive appropriate respiratory care: one was not properly assessed or monitored for CHF and respiratory distress, leading to hospitalization, while another did not have their oxygen tubing changed as ordered, despite staff documentation indicating otherwise. These deficiencies were identified through record review, observation, and staff interviews.
Surveyors found that several residents requiring oxygen and nebulizer therapy had unlabeled and undated tubing, and nebulizer masks were stored improperly. In addition, a resident with chronic respiratory conditions did not have oxygen saturation documented every shift as ordered. Nursing staff and the DNS were unable to explain the lapses or confirm when equipment was last changed, and there was a lack of clear documentation and staff education regarding respiratory care procedures.
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