A resident with COPD, chronic respiratory failure with hypoxia, dependence on supplemental O2, and obstructive sleep apnea had physician orders for CPAP/BiPAP at nap time and night to maintain SpO2 > 92%, and for 3 L O2 via NC if CPAP was refused or unavailable. Progress notes show the resident complained of SOB at bedtime, required a nebulizer treatment, and was placed on continuous O2 via NC after staff noted the CPAP mask was broken and needed replacement. The following day, documentation again noted the broken mask and indicated a new mask would arrive the next day, while the resident remained on O2 via NC. The DON stated that broken masks are reported to the medical supply provider and that a physician should be notified if a resident with respiratory failure has SOB and no mask available, and the supplier confirmed a replacement mask was sent the day after the problem was documented.
The deficiency involves multiple failures in safe respiratory care for residents with tracheostomies, including one resident on high-flow O2 via trach collar who was cognitively impaired and required continuous pulse oximetry but was not adequately monitored, later found with a dislodged trach and pronounced dead after staff attempts at reinsertion and CPR. An LPN caring for this resident reported no trach or respiratory training and did not know the ordered O2 settings, while HR records showed required competency evaluations for two LPNs were not completed. Surveyors observed several trach residents without complete bedside reinsertion supplies or functional pulse oximeters, and one nurse misidentified an Airvo high-flow device as a ventilator and found it turned off. Another resident with a trach had multiple missed physician-ordered trach care, inner cannula changes, and suctioning, and was later hospitalized with pneumonitis, leukocytosis, and tracheal cultures consistent with pneumonia and sepsis. The facility also failed to conduct an incident report, investigation, or required State reporting for the trach-related death, despite policies requiring reporting of accidents and deaths with potential injury.
A resident with severe cognitive impairment, anxiety, dementia, tracheostomy status, and a history of grabbing and pulling at medical devices repeatedly removed her trach collar and other respiratory equipment, and ultimately decannulated herself. Progress notes documented multiple episodes of pulling off the trach collar and vent mask, causing skin tears and repeated disruption of respiratory support, while staff primarily continued to monitor and reposition her. Although staff used an abdominal binder for the G-tube and kept items out of reach, there were no documented care plan interventions specifically addressing her ongoing behavior of pulling at the tracheostomy tube, despite facility policy requiring identification of non-pharmacologic interventions for problematic behaviors.
A resident with a trach and ventilator dependence was observed using a visibly dirty ventilator circuit and a filter labeled with a change date more than 30 days prior, contrary to the facility’s Respiratory Care Equipment and Supplies policy. The resident and spouse reported that the vent circuit had not been changed monthly, and the RT confirmed the circuit and filters were due for 30-day changes but had delayed replacement until the start of the next month. The DON acknowledged that the vent circuit and filter should be changed per the policy, which requires ventilator circuits and air intake filters to be cleaned and replaced every 30 days.
Multiple residents with sleep apnea and complex respiratory conditions had physician orders for nightly CPAP/BiPAP that were not consistently followed or documented, and there was no documentation that masks, tubing, and exhalation ports were cleaned daily as required by facility policy. One resident with acute and chronic respiratory failure and morbid obesity reported not receiving BiPAP the first night after admission and was later found very sleepy with increased respirations and transferred to the hospital for acute respiratory failure and altered mental status, while the record lacked evidence that BiPAP was applied at bedtime as ordered. Other residents reported intermittent CPAP/BiPAP use and one stated the device had not been cleaned for months, and review of MARs, TARs, and notes for all affected residents showed no entries indicating daily cleaning of the CPAP/BiPAP equipment, despite the DON’s expectation that such care be performed and documented.
A resident with COPD, asthma, and dependence on supplemental O2 had a physician order for nightly BiPAP at 20/7 with 25–30% FiO2 via full face mask, with staff to assist in application. A nurse practitioner documented that the resident did not receive the BiPAP, and the MAR showed the treatment as not administered over multiple consecutive nights. During interviews, an LPN confirmed the order but was unsure if the resident actually received BiPAP, and the DON explained that the MAR coding indicated it was not given. The facility could not provide a general policy on following physician orders and only had a BiPAP policy stating that nursing/respiratory staff must verify orders and document appropriately, which was not followed for this resident.
During a facility‑wide power outage when the emergency generator failed, ventilators and other electrical medical devices lost power for several hours, and the facility did not effectively implement its emergency plan requiring manual ventilation and continuous assessment of ventilator‑dependent residents. A resident with chronic respiratory failure and COPD, dependent on full mechanical ventilation via tracheostomy, had no documented respiratory assessments, ventilator checks, or clinical monitoring during the outage, and there was no evidence that manual ventilation was initiated when emergency outlets were found to be nonfunctional. Staffing consisted of one RT and two nurses for numerous ventilator and tracheostomy patients; one RN working a prolonged double shift reported performing minimal checks, not monitoring other residents due to limited staff, and not documenting care because of lack of computer power. The resident was later admitted to the hospital with an elevated lactic acid level and subsequently expired there with chronic respiratory failure and COPD listed as causes of death.
Improper cleaning, dating, and storage of respiratory equipment occurred for a resident with COPD, chronic respiratory failure with hypoxia, and dependence on supplemental O2. Staff did not have the humidification bottle attached to the concentrator, tubing and cannulas were not dated, and a nebulizer mask was left uncovered with dried residue inside. The resident reported nose dryness and said staff had not changed the tubing or cleaned the nebulizer mask after treatments.
Failure to Follow Oxygen Orders and Monitor Oxygen Therapy: Three residents had oxygen-related care that did not match orders or care plans. One resident received O2 at a higher flow than ordered without a physician order, another was observed with an empty portable O2 tank despite orders for continuous oxygen, and a third was repeatedly found lying flat while receiving oxygen at higher-than-ordered flow rates, with an empty humidification canister noted. Staff stated the resident’s oxygen was sometimes turned up because of SOB and that oxygen tanks should be monitored and replaced before becoming empty.
A resident with COPD, chronic hypoxic respiratory failure, CHF, and dementia, who was on chronic 2 L/min O2 via nasal cannula, was transported by stretcher to an outpatient procedure without oxygen. Facility staff had requested transportation that included 2 L of O2, and the dispatcher confirmed the stretcher service itself did not supply oxygen but could accommodate a travel tank from the facility. When the driver arrived, the resident was in bed without oxygen, and staff did not indicate an oxygen requirement or provide a portable tank. The resident was transported without O2 and later arrived at the hospital with an O2 saturation below 90%, with the first documented saturation of 91% after oxygen was applied.
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