Failure to administer oxygen in accordance with the physician order occurred for a resident on continuous O2 therapy. The resident, who had an irregular heartbeat and intact cognition, was observed with portable O2 that was not delivering oxygen because the tank valve was not connected correctly; the resident was unaware the tank was not working, and the DON later found the O2 saturation was 91%. Staff reported that the CNA had set up the portable O2, while the RN stated nurses regulate and administer O2.
A resident with acute pulmonary edema, atrial fibrillation, pulmonary hypertension, and edema was admitted without oxygen therapy and had documented shortness of breath, abnormal lung sounds, and a productive cough, but no respiratory care focus was added to the care plan. Daily skilled assessments contained copied-forward oxygen saturation values and an incorrect COPD reference, and when the resident’s oxygen saturation declined, an LPN initiated continuous oxygen at 2 L/min without documented physician notification or an order. Despite worsening shortness of breath and documentation that the resident became oxygen dependent, staff only notified the practitioner about cellulitis and wound issues, and the resident was later sent to the ED by family, where EMS and ED records showed significant hypoxia and diagnoses including acute hypoxic respiratory failure.
A resident receiving CPAP therapy had no routine cleaning schedule for the CPAP equipment, and staff did not have current CPAP settings available. The resident reported the equipment had not been cleaned since admission and was unsure whether the settings were correct. Orders listed nightly CPAP use, but the settings were not documented, and the care plan did not include cleaning, maintenance, or setting instructions.
Failure to obtain BiPAP orders and accurate settings for a resident with pneumonia, sepsis, and OSA. The MDS and care plan did not reflect BiPAP use, yet the admission assessment documented BiPAP use and the resident was observed using the device in her room. The resident said staff only filled the water tank, while an RN stated BiPAP use should be supported by an order with documented care and on/off times; the ADON, Administrator, and RDCS said they were unaware the resident was using BiPAP.
A resident with obstructive sleep apnea and moderate cognitive impairment used a CPAP machine that was observed to have visible sediment and discoloration on the device, reservoir, and mask, while the resident reported that staff had never cleaned the equipment since admission. Nursing staff, including RNs and an LPN, stated they believed the resident cleaned the CPAP herself, yet the care plan and TAR contained no documentation assigning this responsibility to the resident or ordering staff to perform the cleaning. The DON confirmed the lack of documentation despite facility policy requiring CPAP equipment to be cleaned, stored, and documented per manufacturer instructions and the Infection Prevention and Control Program.
BiPAP Equipment Cleaning Schedule Not Established: A resident with OSA, respiratory failure, and obesity used a BiPAP at night, but staff had not established or followed a routine cleaning schedule for the tubing or facemask. The resident stated the equipment had never been cleaned, and the care plan and treatment record contained no cleaning or maintenance instructions. The DON confirmed the facility failed to initiate a cleaning schedule for the BiPAP equipment.
A resident with a history of respiratory failure and other serious conditions experienced inadequate respiratory care when staff changed oxygen therapy from scheduled to PRN without proper monitoring or consultation with the resident and family. The resident's oxygen levels repeatedly dropped below safe thresholds, monitoring frequency decreased, and documentation was lacking. The resident became lethargic and cyanotic, ultimately requiring hospitalization for respiratory distress.
A resident with multiple medical conditions who used a CPAP machine nightly did not have current CPAP orders or settings entered into the electronic chart, and the use of the CPAP was not included in the care plan. Staff interviews confirmed the omission occurred during a change in responsibility, and facility policy requiring documentation and care planning for respiratory devices was not followed.
A resident with multiple cardiac and respiratory conditions did not receive oxygen therapy as ordered, with observations showing the oxygen flow rate set below prescribed levels and periods when oxygen was not administered at all. Staff interviews revealed inconsistent practices in monitoring and adjusting oxygen delivery, leading to a failure in providing safe and appropriate respiratory care.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
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