PUEBLO, CO- THE CENTER AT PARK WEST

Based on observations, record review and interviews, the facility failed to ensure two (#8 and #1) of three out of 11 sample residents who required respiratory care were provided such care and services consistent with professional standards of practice.

Specifically, the facility failed to:
-Ensure a physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER]
-Ensure Resident #8’s [CONDITION(S)] machine was hooked up to oxygen.

Observations and resident interview

Resident #8 was observed standing in his room on 6/2/21 at 6:08 p.m. Resident #8 said he used a
[CONDITION(S)] machine at night. He said he had been using a [CONDITION(S)] machine for the past two years. He said the night nurse would come into his room at night and help him put on the mask and turn on the machine. He said he did not know the settings on the machine.

The [CONDITION(S)] machine was observed on his night stand, next to the bed. The tubing and mask were hanging on the oxygen regulator, connected to the wall behind his bed. The mask was hanging in the downward position, toward the floor. The oxygen tubing, coming from the wall, was not hooked up to the [CONDITION(S)] machine.

Resident #8 said, when he was at home, the [CONDITION(S)] machine was hooked up to an oxygen concentrator with an oxygen flow of two liters per minute.

The respiratory care plan, initiated on 5/19/21, revealed the resident was at risk for alteration in his
respiratory status and had difficulty breathing related to [CONDITION(S)] ([CONDITION(S)]),
[CONDITION(S)] and coronary artery disease (CAD). The interventions included: Administer
medications/puffers as ordered and monitor for effectiveness and side effects; monitor for signs and symptoms of respiratory distress and report to the physician as needed; and position the resident with proper body alignment for optimal breathing pattern. The intervention that indicated the resident’s [CONDITION(S)] settings was left blank. The care plan did not document the settings of the [CONDITION(S)] and whether or not to ensure oxygen was connected to the machine.

Licensed practical nurse (LPN) #1 was interviewed on 6/2/21 at 6:19 p.m. She said she worked in the hospital at times and had been cross trained as a respiratory aide. She said when a resident was admitted to the facility with the use of a [CONDITION(S)] machine, the nurse should obtain the settings of the machine from the respiratory company who supplied the machine. She said the settings should be verified with the provider and documented as a physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] She said the [CONDITION(S)] machine was used to ensure the resident received enough oxygen while they were sleeping.

She said the night nurse was responsible to ensure the resident was hooked up to the machine, ensure the machine was functioning properly and ensure the settings matched the physician order.
She said Resident #8 used a [CONDITION(S)] machine every night. She said she did not know the settings of the [CONDITION(S)] machine because it was not documented in the physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER]

She said it was important to ensure the [CONDITION(S)] machine was on the correct settings to ensure the resident received the most oxygen at night. She said she attempted to find the settings once she turned on the [CONDITION(S)] machine, however she did not know how to find the settings on that particular machine. She said she would need to contact the respiratory company. She said she did not know what respiratory company was following the machine.