Two residents with tracheostomy or laryngectomy tubes did not receive respiratory care in accordance with facility policy and professional standards. One resident with throat cancer and HIV reported not receiving trach care or suctioning despite documented orders, while surveyors observed uncovered and soiled suction equipment, undated respiratory supplies, and no Ambu bag at the bedside; an LPN could not locate needed trach supplies, described care as merely wiping the stoma, and admitted most nurses needed a skills refresher. Another resident with an artificial airway and cirrhosis had care plan interventions for respiratory monitoring and suctioning, but the health care proxy expressed concerns about staff competency to manage the airway and could not confirm the presence of emergency airway equipment. Interviews with the DON, an RN, and the Medical Director confirmed that clean, dated supplies, complete trach care, and an Ambu bag at bedside were expected, yet these standards were not consistently met.
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with chronic kidney disease on dialysis, cellulitis, and metastatic endometrial cancer received intermittent O2 therapy without a physician’s order or related care plan interventions, contrary to facility policy requiring a specific medical order and respiratory care plan. MAR and vital sign records documented the resident on 2L O2 on multiple occasions, including pre-dialysis, and staff reported the resident returning from dialysis on portable O2, being supplied with O2 tanks for trips, and having O2 in place at the time of death. The Administrator acknowledged that an O2 order should have been in place.
Oxygen was not provided at the ordered rate for a resident with COPD, dysphagia, and Alzheimer’s disease. The resident’s order specified 2 L/min via NC continuously, but surveyors observed the concentrator running at 3 L/min while the resident was sleeping in bed on multiple occasions. An LPN acknowledged the oxygen was running above the ordered rate and stated the flow level was not checked during med pass, and the ADON confirmed staff needed to follow the physician’s order.
Respiratory Treatment Orders and Oxygen Delivery Not Followed: Two residents did not receive respiratory care consistent with physician orders. One resident’s CPAP order lacked settings and administration details, and the TAR had no documented CPAP administration despite ongoing references to CPAP use. Another resident ordered for O2 at 2 L/min was repeatedly observed receiving 3.5 L/min, and the LPN unit manager confirmed the ordered rate was not followed.
Oxygen was administered to a resident without a valid physician order. The resident had lung cancer, PE, and acute respiratory failure, and was receiving oxygen via NC after returning from the hospital. Surveyors observed the NC on the floor and later found the concentrator set at 0 L/min, while the EHR contained no order for oxygen during the period reviewed. An LPN could not locate an order, and the MD later stated there had been no previous order even though oxygen had been continued.
Failure to provide and document ordered CPAP care for a resident with OSA. The resident’s CPAP was not documented as being applied at bedtime on multiple occasions, and required care such as filling the water chamber and cleaning the mask and tubing was also not documented. The resident had OSA, DM2, and prior CVA-related weakness, and the chart lacked a respiratory care plan, an order for daily CPAP removal, oxygenation monitoring, and staff education/training for CPAP use.
Oxygen Delivered at Incorrect Flow Rate: A resident with COPD, DM2, and asthma had a physician order and care plan for continuous O2 at 4 L via NC, but was observed receiving 2 L via NC. The resident stated they had been on 2 L for years, while an LPN said the resident was always on 2 L and did not check the order daily. An RN unit manager stated oxygen should have been given as ordered, and the DON noted the TAR did not show the order and could not explain the discrepancy.
A resident with severe cognitive impairment, dysphagia, and a stage 4 sacral wound on enhanced barrier precautions received oxygen via nasal cannula at a higher flow rate than ordered, with the concentrator repeatedly observed at 3 L/min instead of the prescribed 2 L/min. An LPN acknowledged not verifying the exact oxygen order and failing to adjust the flow rate to match it. In addition, a CNA handled and reinserted the resident’s nasal cannula from the resident’s hair into the nostrils without performing hand hygiene or using required PPE (mask, gloves, gown), despite the resident being on enhanced barrier precautions.
A resident with respiratory failure, OSA, and a history of pulmonary embolism had an active physician order and care plan for continuous O2 at 4 L/min via nasal cannula. During a visit, the resident reported breathing difficulty; the health care proxy found the concentrator not delivering air as expected and was unable to get staff assistance, after which the resident’s granddaughter independently connected the nasal cannula to a portable O2 tank of unknown flow. When a Respiratory Therapist later assessed the resident for reported SOB, the resident was on 3 L/min from the portable tank with SpO2 of 92% and was then switched to the concentrator at 3 L/min. The RT did not verify the current O2 order and stated they were unaware the resident was ordered 4 L/min, relying instead on a prior recollection of a 3 L/min setting, resulting in O2 being provided at a lower flow than prescribed.
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