Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as evidenced by observations and staff interviews. Resident R9, who had diagnoses including hypertension, diabetes, and sleep apnea, was observed receiving oxygen therapy without a date on the nasal cannula and humidification bottle. Additionally, the CPAP mask was not stored in a bag when not in use. Licensed Practical Nurse (LPN) Employee E8 confirmed these observations. Resident R20, diagnosed with respiratory failure, hypertension, and diabetes, also had a CPAP mask that was not properly stored in a bag, as confirmed by LPN Employee E1. Resident R205, with diagnoses of pneumonia, anemia, and asthma, was observed with a nebulizer on the nightstand, but the nebulizer tubing was not dated and not stored in a bag when not in use. Registered Nurse (RN) Employee E2 confirmed these observations. The Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care for these residents, which is a violation of the facility's policies on oxygen administration and infection prevention and control.
Plan Of Correction
The director of nursing/designees completed an audit of Oxygen Tubing/Bipap/ Nebulizers to review all respiratory equipment currently in use to ensure that each required item is properly dated and stored as per infection control guidelines. Any items undated or improperly stored were removed and replaced at the time of discovery. All residents with oxygen tubing or nebulizers had the potential to be affected by the alleged deficient practice. There were no known negative outcomes. The DON/Designee will provide training for nursing and respiratory therapy staff on the proper procedure for dating and storing respiratory equipment. This training will include the appropriate technique for labeling oxygen tubing, nebulizer equipment, and storing bipap masks with the correct date of use and the recommended duration for tubing replacement according to infection control policies. The DON/Designee will conduct weekly audits of respiratory equipment to ensure proper labeling and storing is completed for four weeks. Results of audits will be submitted to the QAPI committee to review and identify any trends that may require further follow-up recommendations.