Deficiencies in Emergency Equipment and Oxygen Filter Maintenance
Penalty
Summary
The facility failed to provide necessary emergency tracheostomy equipment at the bedside for a resident with a tracheostomy, identified as Resident #86. During the survey, it was observed that the required emergency supplies, such as an obturator and appropriately sized inner cannulas, were not available at the resident's bedside or in the supply room. The primary nurses responsible for the care of the resident were not familiar with the obturator or its use, indicating a lack of training and awareness among the staff. Additionally, the facility did not ensure the cleanliness of oxygen concentrator filters for three residents, identified as Resident #33, Resident #44, and Resident #60. Observations revealed that the concentrator inlet filters for these residents were covered with a gray/white substance, indicating they had not been cleaned as required. The Maintenance Director, who was responsible for cleaning the filters, admitted that the filters had not been cleaned until the day of the survey, despite documentation suggesting otherwise. These deficiencies highlight a failure in the facility's processes to ensure the availability of critical medical supplies and the maintenance of equipment necessary for resident care. The lack of emergency tracheostomy equipment and unclean oxygen concentrator filters posed significant risks to the residents' health and safety.
Plan Of Correction
Resident #86 was provided with the proper emergency equipment at his bedside and nursing staff were educated and competencies were completed. Resident #86 is the only resident currently in Alaris Health at Belgrove with [R]. On 12/3/24 upon receiving notification of the Immediate Jeopardy situation, the Director of Nursing in serviced LPN3 and RN1 assigned to work 3-11 shift on the first floor where Resident #86 resides on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. Director of Nursing and/or Infection Preventionist also inserviced the LPN4 and RN2 assigned to the 1st floor for 12/3/24 11-7 shift on Trach Care, Emergency Trach Care and identifying supplies needed. Competency and return demonstration was completed. This was completed prior to start of the shift. Director of Nursing and/or Infection Preventionist repeated this process for RN3, LPN2 and RN4 assigned to the first floor on 7-3 shift 12/4/24 prior to the start of their shift. Starting on 12/4/24, this education and competency will then be completed on all nurses in the facility. Any nurse caring for Resident #86 will be inserviced prior to the start of their shift. Any nurse that is on leave or vacation will receive this education and competency on their first shift upon return. This education and competency will be incorporated in the orientation process for all new hires starting on 12/4/24. The [R] for residents #33, #44, and #60 were cleaned by the Director of Maintenance and replaced back on the [R]. All residents with tracheostomies and all residents that use oxygen supplementation via oxygen concentrators are potentially affected. Nursing Supervisor will check the supplies in Resident #86 room and any residents with tracheostomy q shift for the next 3 months to assure that all required supplies are present in the room. For Resident #86 these supplies include Tracheostomy Care Kit, Ambubag, Suction Machine, Suction Kit, Normal Saline Bottles, Sterile Water Bottles, Drain Gauze, Sterile Gauze, Inner Cannulas (#6), Tracheostomy Set for Emergency Use (includes outer cannula, inner cannula, obturator, trachea ties, size #5), Corrugated Tubing, Yankeauer Suction Catheter, Velcro Trach Ties, Suction Connecting Tubes, Aerosol Drainage Bag w/ Y-Adaptor and Straight Adaptor. Central Supply Coordinator will maintain a weekly inventory of trach supplies. Inventory will be submitted to the Director of Nursing on a weekly basis for review. Director of Nursing will instruct Central Supply Coordinator on a weekly basis of any supplies that need to be ordered. If a potential admission is identified requiring trach supplies, the Director of Nursing will identify supplies needed and assure supplies are available in building prior to admission. Director of nursing or designee will inservice nurses upon hire and annually on tracheostomy care and care of the tracheostomy in an emergency. Director of nursing or designee inserviced the maintenance department on properly cleaning oxygen concentrators filters. Policy of care of the oxygen concentrator was revised to clean filters weekly by the maintenance department. QAPI was implemented to not only address immediate rectification, but also to maintain an ongoing system to ensure proper trach care and supplies present for residents who need. Within this QAPI there will be continued education with all nurses on Trach Care, Emergency Trach Care and supplies needed. The Director of Nursing, Infection Preventionist and/or designee will conduct 5 observations per week of nurses performing trach care and reviewing emergency trach care and supplies starting 12/9/24. Any nurses noted with deviation from standard of practice will be immediately reinserviced and have a successful competency completed prior to being able to care for a resident with a trach. Maintenance director or designee will audit 5 oxygen concentrators weekly to assure they are properly cleaned. Results of these audits will be reported to the Administrator on a weekly basis for review for the next 3 months. QAPI meeting will be held on a monthly basis to ensure proper procedures regarding cleaning of the concentrator filters, trach care, emergency trach care and availability of proper supplies are in place and followed for the next 2 months and quarterly thereafter for the next year.
Removal Plan
- All nurses, including new hires, will be educated on tracheostomy care, emergency tracheostomy care, and identifying supplies needed with competency and return demonstration.
- A nursing supervisor will check the supplies in Resident #86's room to assure all required supplies are present in the room.
- Central supply will maintain inventory of tracheostomy supplies.
- The DON will assure tracheostomy supplies are available prior to admission.