A resident with CHF, interstitial lung disease, and chronic respiratory failure was receiving O2 via nasal cannula with humidification at 3 LPM. Facility policy required routine changes of oxygen delivery devices, and the MD order specified weekly changes of oxygen tubing and related supplies with staff to initial and date them. During observation, the surveyor noted the tubing tag showed a change date several weeks earlier, and a CNA confirmed this date despite stating tubing is changed weekly. The DON later acknowledged that the tubing should be changed weekly and that the facility missed changing this resident’s oxygen tubing as ordered.
A resident with COPD and pulmonary hypertension was admitted with a hospital discharge order for 2 L/min oxygen at night, but the facility did not transcribe this order into the medical record. Admission documentation conflicted about whether the resident used supplemental O2, yet an oxygen care plan was initiated without specifying flow rate or frequency. Nursing notes later showed the resident receiving 2 L/min O2 via nasal cannula and then 3 L/min as documented by an NP, all without an active oxygen order. When an O2 order was finally entered, it only directed staff to titrate to keep SpO2 above 90% and did not specify flow rate or duration (continuous vs. nocturnal), and there was no documented ongoing monitoring to ensure the resident’s oxygen saturation remained above the ordered level.
Failure to Provide and Monitor Ordered BIPAP Therapy: A resident with OSA and respiratory failure had an order for BIPAP, but the settings were left blank in the admission order, staff did not verify proper settings, and repeated refusals were not escalated to the physician. Facility records showed BIPAP use was documented despite remote DME data showing little to no actual use, and the resident later required ER transfer for worsening hypoxia and hypercarbia, with the ER noting chronic BIPAP nonuse as the likely cause of the exacerbation.
Surveyors found that staff did not consistently clean or document cleaning of CPAP/BiPAP/AVAP equipment as ordered and per facility policy for three cognitively intact residents using respiratory support devices. One resident with obstructive sleep apnea and paraplegia had a daily AVAP mask cleaning order, but the treatment record lacked the cleaning order on a key date, and the resident reported mask cleaning was not done and later developed facial cellulitis. Another resident with obesity and obstructive sleep apnea had weekly CPAP cleaning orders but reported the mask was washed only once since admission, and the treatment record showed missed cleanings marked with a code requiring nursing notes that were not present. A third resident with acute and chronic respiratory failure had a daily BiPAP mask cleaning order, was unsure if cleaning occurred, and had at least one day without documented cleaning. An LPN stated nurses were responsible for cleaning and documenting, and the DON confirmed the expected daily mask and weekly tubing cleaning and acknowledged missing documentation.
Two residents received oxygen and non-invasive ventilation without corresponding physician orders or MAR/TAR documentation, contrary to facility policy requiring ordered, care-planned oxygen therapy with specified equipment settings and monitoring. One resident with COPD and chronic hypoxic respiratory failure had physician notes indicating a need for long-term oxygen and specific saturation goals, yet no oxygen orders were present while oxygen equipment was in the room and in use, including during smoking episodes. Another resident with muscle wasting, morbid obesity, and obstructive sleep apnea was reported by the ADON and an LPN to use BiPAP/CPAP with oxygen at night, but no orders for oxygen or BiPAP/CPAP were found in the physician orders or MAR/TAR when requested by surveyors.
A resident with acute and chronic respiratory failure, CHF, and mantle cell lymphoma was observed receiving oxygen by NC at 2 LPM, but the chart had no physician order or MAR documentation for oxygen administration. The facility policy required a physician order and documentation of the flow rate, route, and rationale, and an RN confirmed the resident had no oxygen order before a later order was obtained.
Staff failed to follow facility policy and MD orders for respiratory care when a resident with COPD, acute and chronic respiratory failure with hypoxia, acute pulmonary edema, and heart failure received nebulizer treatments. Although the MAR showed that nebulizer treatments were given and the resident self-administered them after nurse set-up, nursing staff did not consistently assess or document required pre- and post-treatment parameters such as lung sounds, pulse, respirations, and oxygen saturation as directed. The DON confirmed that nebulizer assessments should be documented on the MAR and that this was not consistently done for this resident.
A resident with COPD, morbid obesity, alveolar hypoventilation, history of pulmonary embolism, and dependence on supplemental O2 had an order for 2–4 L via nasal cannula to maintain SpO2 > 90%, with tubing changes as needed. An RN changed the resident’s oxygen tubing but did not turn the oxygen back on, and the resident’s attempts to summon staff using the call light and phone went unanswered. A CNA later found the oxygen off during morning rounds and turned it back on, confirming the resident’s report that the oxygen had been off for most of the night, while the regional nurse consultant was unaware the resident had been without oxygen.
A resident with COPD was found to have a nebulizer mask left uncovered on the bedside table when not in use, contrary to facility policy requiring respiratory equipment to be stored in a plastic bag. Both an LPN and the DON confirmed the mask should have been covered, and observations on multiple occasions documented the deficiency.
A resident with a tracheostomy did not receive care consistent with professional standards when an LPN failed to maintain sterile technique and proper hand hygiene during a tracheostomy care procedure. Supplies were placed on an unclean bedside table, sterile items were contaminated, and hand hygiene was not performed after glove removal. The LPN also did not check the resident's neck for skin breakdown as required.
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