Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents, as observed by surveyors. Resident #19 was found with an oxygen concentrator and nasal cannula tubing that was not labeled, dated, or stored in a protective covering. The resident's medical records indicated a need for oxygen therapy, but the tubing was not managed according to the facility's policy, which required weekly changes and proper labeling to prevent contamination and infection. Interviews with the LPN/UM and the Infection Preventionist confirmed that the facility's policy was not followed, as the tubing was not labeled or stored correctly. Resident #54 was observed receiving oxygen through nasal cannula tubing that had been in use for twelve days without being changed, contrary to the physician's order for weekly changes. The tubing was labeled and dated, but there was no storage bag observed, which is required to prevent contamination. The facility's policy mandates that respiratory equipment be stored in a labeled and dated bag when not in use, but this was not adhered to, as confirmed by interviews with the LPN/UM and the Infection Preventionist. Resident #239 was found with a tracheostomy tube connected to an oxygen concentrator, but there was no physician's order for oxygen administration in the resident's medical records. The facility's policy requires a physician's order for oxygen use, except in emergencies, but this was not obtained for Resident #239. The DON confirmed the absence of the necessary order, acknowledging the oversight. The facility's failure to follow its own policies and obtain the required physician's orders for oxygen administration contributed to the deficiencies identified by the surveyors.
Plan Of Correction
1. Residents affected by deficient practice: The facility failed to ensure NU Ex Order 26.4(b)(1) equipment was stored and dated properly and ensure a physician's order was in place for a resident who received Exer. Resident #19's NJ Exec Order 26.461 was replaced, correctly labeled, dated, and stored in a protective covering on 12/3/24. Resident #54's NJ Exec Order 26.461 was replaced, correctly labeled, dated, and a dated storage bag was provided on 12/3/24. Resident #239 was discharged from the facility. 2. Identifying other residents who could be affected by the deficient practice: Residents that require oxygen therapy could be affected by this deficient practice. An audit of all residents who require oxygen was completed to ensure orders in place, care plan in place, and all equipment dated and bagged. No other concerns were identified. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed nurses were in-serviced by the Assistant Director of Nursing on the policy/process of residents requiring oxygen therapy. The in-service included that respiratory tubing gets changed, bagged, and dated each Wednesday on the 11-7 shift, and licensed nurse is to ensure the oxygen liter flow on the concentrator matches the oxygen order in PCC. 4. Monitoring the continued effectiveness of the systemic change: Unit Managers/Designee will conduct audits of residents requiring oxygen to ensure orders, care plans, and all equipment is in place weekly x 4 then Monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.