The facility failed to store oxygen tubing, NCs, and masks in a sanitary manner for three residents, and one resident had no oxygen order. A resident with respiratory failure and CHF was observed with an uncovered NC in a plastic bag on the floor, another resident with COPD had oxygen tubing and an NC lying on the floor and later hanging off the bed without a plastic cover, and a third resident with chronic respiratory failure, COPD, and Alzheimer’s disease had oxygen tubing and an NC on a food tray and a nebulizer mask on the overbed table. Staff stated the NC should be stored in a plastic bag when not in use, and the DON stated tubing/NC/masks should always be stored in a clear plastic bag and not reused after being dropped on the floor.
A resident with chronic respiratory conditions did not receive supplemental oxygen at the physician-ordered flow rate. Observations showed the oxygen concentrator was set below the prescribed 3 L/min on multiple occasions, and staff interviews confirmed the settings did not match the order, resulting in a failure to follow facility policy for respiratory care.
A resident with acute respiratory failure and hypoxia did not receive oxygen therapy as ordered, with observations showing oxygen administered at a higher flow rate than prescribed and tubing not changed according to the physician's schedule. Documentation by nursing staff did not match actual practice, and both an LPN and the DON confirmed the discrepancies in oxygen administration and tubing change frequency.
A resident with chronic respiratory failure and ventilator dependence did not receive tracheostomy tie changes as required by facility policy, and there was no documentation of these changes for an entire month. Staff interviews confirmed that the order for trach tie changes was not consistently maintained or documented, leading to a lapse in care.
A resident did not receive safe and appropriate respiratory care when needed, as required by facility protocols.
A resident with intellectual disabilities was administered continuous oxygen therapy at two liters per minute without an active physician order. Staff observations and interviews revealed that an LPN believed an order was in place, but had not recently verified it, while the NP confirmed the order had been discontinued and was unaware oxygen was still being given. The DON stated staff should check orders with each assessment, but the resident continued to receive oxygen therapy without a valid order.
A resident with significant respiratory conditions was observed receiving oxygen at a lower flow rate than prescribed by the physician. Despite orders and care plan interventions specifying 4 L/min during ambulation and 2 L/min at rest, the oxygen concentrator was repeatedly set at only 1 L/min. This discrepancy was confirmed by the DCE during the survey.
Two residents with respiratory and cardiac conditions did not receive oxygen at the flow rates ordered by their physicians. Observations found one resident receiving a higher flow rate and another a lower flow rate than prescribed. Nursing staff confirmed the discrepancies and adjusted the oxygen settings after discovery. The DON acknowledged that oxygen should be administered according to physician orders.
The facility failed to maintain proper hygiene and maintenance of oxygen equipment for three residents, including undated tubing and dusty concentrators. The DON confirmed these deficiencies, which were contrary to the facility's policy requiring weekly changes and cleaning.
A resident was receiving oxygen without a physician's order, contrary to the facility's policy requiring such orders. The resident, who had moderate cognitive impairment, was observed receiving oxygen at 3 LPM via nasal cannula. A nurse confirmed the absence of an active order for oxygen, noting that even in acute situations, an order should be obtained.
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