The facility failed to administer oxygen as ordered for three residents who experienced low O2 saturations. One resident had an O2 saturation of 89% on RA with an order to apply O2 to keep saturations above 90%; staff notified an RN, who assessed the resident, called 911, and prepared transfer paperwork but did not apply O2 or recheck the saturation before transfer. A second resident, care planned as at risk for respiratory distress with orders to maintain O2 saturations above 90%, became lethargic with an O2 saturation in the low 80s on RA; the RN called the POA and 911 and left the room for paperwork, and later could not recall if O2 was applied, with no documentation that it was. A third resident had documented O2 saturations in the high 80s on RA; the RN contacted the provider and believed they may have applied O2 but had no documentation of doing so before ambulance transfer. The DON confirmed that O2 was readily available, that orders required O2 when saturations remained below 90%, and that these residents had documented low O2 saturations without documented O2 administration, and that one resident’s care plan goal for O2 saturation was not met.
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
Respiratory care was not provided as ordered for several residents. A cognitively intact resident using a Trilogy NIV had no documented device settings or record of when the mask and tubing were last changed, another resident ordered for continuous oxygen titration had only daily SpO2 checks instead of more frequent monitoring, and two residents had oxygen tubing that was not dated. The DON confirmed the missing settings, limited SpO2 monitoring, and lack of tubing dating.
A resident with obstructive sleep apnea had a provider order for nightly BiPAP use and relied on staff for equipment care, but the facility failed to replace the BiPAP mask and tubing according to its own policy and provider recommendations. Over several observations, the mask and tubing were seen lying on the bed, sometimes lodged between the mattress and side rail, and the mask appeared cloudy with dried white spots. An LPN reported that central supply was responsible for respiratory equipment changes, while central supply staff stated they were unaware the resident used a BiPAP and had not ordered or changed any supplies. The DON confirmed the resident’s respiratory equipment had not been replaced as required.
The facility failed to maintain complete respiratory orders for two residents on oxygen and one resident using a PAP device. One resident’s oxygen order lacked a dose and route, another resident’s oxygen order lacked a dose, and a third resident had documented PAP use in progress notes and at bedside but no physician order. Staff and the ADON confirmed the missing order details, while observations showed the residents using oxygen at 2 L/min and the PAP machine in the room.
A resident with obstructive sleep apnea had a CPAP machine in the room, and the MDS and care plan documented CPAP use and risk for altered respiratory status. However, the order summary contained no physician order for CPAP pressure settings, and the DON and an LPN confirmed the EMR lacked an order; the CCL stated the facility did not have a system to ensure residents admitted with a personal CPAP had an order.
A resident with heart failure did not consistently receive BiPAP therapy as ordered, with multiple missed applications documented over several weeks. Staff interviews revealed poor communication and lack of clarity regarding responsibility for applying the BiPAP mask, and there was no documentation of resident refusal when the therapy was not provided.
Two residents requiring CPAP therapy for conditions such as sleep apnea and respiratory failure had physician orders that lacked specific settings, including pressure, ramp time, and humidity. The DON confirmed that the orders were incomplete and that staff could not identify the intended settings, despite facility policy requiring verification of such details before initiating CPAP therapy.
A resident with chronic respiratory conditions did not receive oxygen therapy as ordered by the physician. Staff set the oxygen concentrator above the prescribed flow rate and failed to ensure the resident wore the nasal cannula, resulting in low oxygen saturation levels before intervention by a nurse.
Two residents requiring noninvasive ventilator support did not have care plans reflecting the use of a Trilogy machine, and staff had not received training or competency testing for its use. Despite physician orders and the presence of the machines at bedside, only some nurses were able to assist residents appropriately, as confirmed by both resident interviews and the DON.
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