Respiratory care was not provided as required for multiple residents receiving O2 therapy. Surveyors observed unlabeled O2 tubing, a humidifier bottle on the floor, tubing left on a nightstand without a protective bag, and missing Oxygen In Use signs outside several resident rooms. An LPN confirmed tubing and masks were expected to be labeled and stored in a clean plastic bag when not in use, and the DON acknowledged the findings.
Surveyors found that a resident with a physician’s order for continuous oxygen at 2 L for comfort was not receiving oxygen despite the presence of an oxygen concentrator at the bedside. Across multiple observations, the concentrator remained off and the nasal cannula was coiled on top of the machine rather than in the resident’s nostrils. Review of the MAR showed that six licensed nurses, including RNs and/or LPNs, had documented each shift that the resident was receiving oxygen as ordered, despite the lack of actual oxygen administration. The DON and administrator were informed that the medical record had been falsified, and the DON confirmed the findings.
Oxygen tubing was not dated or labeled for two residents receiving O2 via nasal cannula. One resident had continuous O2 for COPD and the other had O2 PRN for SOB; both had orders for weekly tubing and humidifier changes with labeling after each change. During observations, an LPN, RN, and DON confirmed the expectation that tubing should be changed weekly and dated.
A resident receiving continuous O2 via nasal cannula had an empty humidifier canister attached to the concentrator, and the tubing/cannula was not initialed or dated. The resident’s order required weekly changes of the tubing and humidifying bottle, but the equipment was overdue and the humidifying water was not present when observed.
Safe respiratory care was not provided when an unsecured O2 tank was observed at the nursing station and two residents with active O2 orders had emergency O2 tanks in their rooms without the required door signage. One resident’s tank was stored in a wheelchair pocket in the bathroom, and another resident’s tank was secured in an O2 stand, but neither room had signage indicating the presence of an emergency O2 tank.
The facility failed to provide ordered respiratory care for three residents receiving O2 therapy. Two residents were observed with unlabeled O2 tubing, and their records showed orders for weekly tubing changes and labeling per protocol. Another resident was observed receiving O2 at 2.5 L/min even though the order was for 2 L/min, and staff stated they sometimes increased the flow without an order; the resident also had no care plan for oxygen administration.
A facility failed to provide respiratory care that matched physician orders for multiple residents receiving O2. One resident was found on nasal cannula O2 without an active order for flow rate, and staff relied on shift report rather than verifying the EHR, resulting in incorrect flow settings. Other residents had O2 tubing that was not dated or labeled as expected, and one resident’s O2 was set below the ordered rate until staff adjusted it after observation.
Two residents did not receive respiratory care in accordance with professional standards. One resident with obstructive sleep apnea had a hospital discharge summary directing continuation of BiPAP for sleep, but BiPAP was neither ordered nor documented as administered for the first three nights after admission. Another resident with COPD, asthma, chronic myeloid leukemia, and a history of acute on chronic hypoxic hypercapnic respiratory failure had intermittent oxygen use documented in vital signs, yet there were no physician orders for oxygen therapy, tubing changes, humidification, O2 saturation goals, or basic oxygen care, despite facility policy requiring a provider order specifying liter flow and delivery device; the DON confirmed the absence of related documentation on the MAR and TAR.
Oxygen Therapy Given Above Ordered Rate: A resident with acute respiratory failure with hypoxia was observed receiving O2 via nasal cannula at rates higher than the ordered 2 L/min, including 3.5 L/min and later 7 L/min. The RN stated the O2 use fluctuated and could be titrated for panic attacks, but the chart had no order allowing titration and no documentation supporting the reported low O2 sat episode.
Respiratory care was not provided consistently with orders and facility protocol for three residents. An LPN and Unit Manager found oxygen tubing, humidifier bottles, nebulizer tubing, and suction catheter left unlabeled or undated, and one resident’s record lacked an order for weekly oxygen equipment changes even though staff said that was the facility practice. Another resident had oxygen in use with an undated nasal cannula and a humidifier bottle dated earlier than the review, while active orders later confirmed weekly nebulizer equipment changes for a third resident.
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