Deficiency in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for five residents, as evidenced by a review of facility policy, clinical records, observations, and staff interviews. The facility's policy on 'Respiratory Therapy' outlines procedures to prevent infection associated with respiratory therapy tasks and equipment, including changing oxygen cannula and tubing every seven days and storing circuits in a plastic bag with the date and resident's name. However, these procedures were not consistently followed for the residents involved. Resident R2's clinical records showed a lack of specific oxygen saturation parameters in the physician's orders, which were only updated after a nurse spoke with a hospice practitioner. Resident R70's oxygen tubing was not dated as required, and Resident R77's nebulizer tubing and mask were found unlabeled and not stored in a bag. Similarly, Resident R103's nebulizer was not stored in a bag, and Resident R317's oxygen tubing and humidifier bottle were not labeled with a date. Interviews with nursing staff confirmed these deficiencies, and the Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care and maintain oxygen equipment for the affected residents. The report highlights the facility's non-compliance with its own policies and the regulatory requirements for respiratory care, as outlined in 28 Pa. Code: 211.10(c) (d) and 211.12(d)(1)(2)(3)(5).
Plan Of Correction
Resident R'2 orders were corrected to include an oxygen saturation percentage at the time of survey. All residents identified in the citation were checked and provided with new oxygen tubing, humidification bottles, nebulizers, and bags for storage as required at the time of survey. A whole house audit was completed for all residents receiving respiratory care for dating, labeling, and storage on 1/21/25. The DON or designee will educate all licensed nursing and respiratory staff on the policy for respiratory therapy. The DON or designee will audit all respiratory care equipment for labeling, dating, and storage daily for 3 days, then 5 residents weekly for 8 weeks. All results will be reviewed through QAPI for further recommendation.