Failure to Provide Proper Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident, identified as Resident 28, who required respiratory care. The deficiency was identified through observation, clinical record review, and interviews. According to the clinical records, Resident 28 had a physician's order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation levels above 91 percent. However, it was noted that the resident last used oxygen on March 28, 2025, and during observations on April 8 and April 9, 2025, an oxygen concentrator was found beside the resident's bed with an undated humidification cannister and unbagged, undated nasal cannula tubing draped over the concentrator and onto the floor. The resident confirmed during an interview on April 8, 2025, that they had not used oxygen recently. The American Association for Respiratory Care emphasizes the importance of proper cleaning of respiratory equipment to reduce infection risk, which was not adhered to in this case. The findings were reviewed with the Nursing Home Administrator on April 10, 2025, highlighting the facility's failure to ensure proper respiratory care and equipment maintenance for Resident 28.
Plan Of Correction
Oxygen concentrator for resident 28 was removed from the room due to non-use. Residents utilizing oxygen will be reviewed to ensure the need for respiratory equipment in their room. Equipment not in use will be removed. Equipment being utilized will be checked to ensure that it is dated and bagged appropriately. Nursing and housekeeping staff will be educated on oxygen equipment dating and bagging will be completed. Staff will be further educated to remove medical equipment upon resident admission to the hospital. Clinical coordinators/ RN supervisors or designee will check rooms of residents that are transferred to the hospital to ensure no respiratory equipment that is not in use remains. This audit will be completed weekly for 4 weeks. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.