Ftag of the Week – F695 Respiratory/ Tracheostomy Care and Suctioning (Pt 2)

In Part 2 of our CMSCG “Ftag of the Week” for F695 Respiratory/Trach Care, we will begin to review the importance of staff knowledge of what needs to be provided for different types of respiratory care and services. F695 requires that facilities assess and develop individualized plans of care that are based on professional standards of practice – and importantly – provided by qualified and competent staff. Interventions must be delivered across all shifts consistently. That leaves lots of room for “gotchas” on survey.

Oxygen Therapy

Let’s start with supplemental oxygen therapy – it seems pretty simple, but the citations are plentiful, which indicates staff don’t have a good handle on everything that needs to be done. If a resident is receiving O2 therapy, his/her record must reflect that there is a physician’s order with indication for use, the resident’s respiratory status is being monitored on an ongoing basis and the resident’s response to therapy is documented.

CMSCG Clinical Consultant Mary Quinn, RN, provided the following insight related to oxygen therapy:

Most facilities are able to provide supplemental oxygen when it is required by a resident, but the mechanism of delivery can vary greatly. Equipment may include the provision of oxygen through nasal cannulas, trans-tracheal oxygen catheters, oxygen canisters, cylinders, concentrators. The order should include the concentration of oxygen to be delivered, the method of delivery, whether the use should be continuous or prn, as well as the rationale for use.  Application of PRN oxygen should be based on an assessment i.e., oxygen saturation. Residents’ vital signs should be monitored, inclusive of oxygen saturation.

It’s important to recognize that Facilities are being cited for oxygen being in use, without a physician’s order.  Let’s take a look at how that may happen.

  • Residents may arrive at a facility with oxygen in use.   If oxygen is automatically applied during transport and continues without an order, you have set yourself up for citation.
  • Many facilities have a policy that permits the emergency administration of oxygen. Policies typically indicate a physician order is needed if the oxygen delivery is continued beyond a certain time frame i.e.  24 hours. Many times, the order is not entered but documentation reflects the continued use of oxygen.

Another common citation is that facilities are being cited for oxygen not being administered as ordered. Here’s a few ways that is observed:

  • Depending on the delivery system, the oxygen source may empty. Unless the oxygen source is continuous (i.e., walled oxygen, concentrators), you have to have a system in place to monitor/replace equipment such as e- tanks, transport tanks.  Are your residents changed from a concentrator to an e- cylinder when they attend meals/activities etc. – any of them empty?
  • The order is for continuous oxygen administration, but the resident is observed without oxygen.  Residents may no longer require the continuous use of oxygen as their condition improves i.e., pneumonia, but the orders need to be followed as entered.  Ongoing assessment of the resident’s respiratory status and response to oxygen use must be reflected in the record.  
  • During the height of the COVID 19 pandemic there was a dramatic increase in the need for supplemental oxygen use – have you reviewed your orders to make sure they are consistent with the current needs of the resident?  Does everyone with an oxygen prn order still need that order?  You need to get your medical staff on board with the ongoing assessment of a resident’s respiratory status and the need to continue oxygen orders.
  • Administration flow rate doesn’t match the order – is the resident manipulating the flow by himself? If so, is this documented and as well as physician notification and resident education? Does the resident self-remove their oxygen? Is this documented – and what is the plan for monitoring?  And, don’t forget to check the flow rate after a “concerned” family member visits, who has a known history of adjusting the flow rate because the family member thinks it is better for mom/dad.

If those aren’t enough examples to make you want to go back and look at your systems related to oxygen therapy, don’t forget about this list of areas that can also be tagged, such as:

  • Resident missing a desired activity/appointment due to no portable tank being provided
  • Physician notification
  • Signage not on doors where oxygen is in use, or the signage does not include all necessary information
  • E- tanks not secured properly – look in the corners of the resident rooms since sometimes they are hiding there
  • Oxygen storage – where?  Does the storage area clearly indicate which cylinders are  full or empty?
  • Maintenance of equipment- i.e., master equipment list to ensure safety inspections are completed. You should also have a PMP in place for checking concentrators as you might be cleaning the external filter, but what about the internal filter/s
  • Emergency management – i.e., power outage – do you have enough generator plugs?
  • Infection control concerns related to storage/handling. There is no requirement related to the frequency that equipment must be changed, but it should be addressed in your policy and compliance monitored.
  • Resident education- safety related to ambulation/smoking, etc.
  • Pressure ulcers- monitor skin i.e., nares/ears if nasal cannula is in use
  • Medical record s- omissions i.e., prn administration reflected in notes, but not captured on the MAR/TAR
  • If your use of certain equipment is infrequent, ensure supplies are not available for use beyond their expiration date

Next week on the CMSCG Blog, we’ll review some other regulatory requirements and things to be aware of related to F695. We haven’t forgotten about ventilator use, which is a high-risk area, and will be covered in an upcoming post. Missed Part 1? View it here.

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