Failure to Adhere to Respiratory Care Standards
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident requiring such care. The facility's policy on aerosol therapy mandates that nebulizer equipment should be cleaned and dried after each use, with disposable parts replaced weekly. However, a review of Resident 50's clinical records revealed a lack of specific orders regarding the frequency of nebulizer tubing and mask changes or the cleaning of the medication chamber and mask. Observations in the resident's room showed that the nebulizer tubing was not dated, and the mask was left on top of the machine instead of being stored in a bag. Resident 50 has a medical history that includes chronic diastolic congestive heart failure, atrial fibrillation, and chronic respiratory failure with hypoxia. The resident had a physician's order for Ipratropium-Albuterol Inhalation Solution to be administered via nebulizer four times a day. During an interview, the Director of Nursing indicated that the nebulizer tubing should be dated and the mask bagged when not in use, which was not the case for Resident 50, leading to the deficiency noted in the report.
Plan Of Correction
1. Upon discovery, the R 50 had their tubing dated and bagged. 2. No other residents were identified with missing tubing or bags. Education was provided by the DON/designee on proper labeling and storage of respiratory equipment. 3. An audit will be conducted for 5 patients on respiratory equipment weekly x 2 weeks then monthly x 2 months to ensure that respiratory equipment is properly stored and dated. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.