Deficiencies in Respiratory and Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care, including tracheostomy care and tracheal suctioning, for four residents. Resident R10, diagnosed with emphysema and dyspnea, was observed receiving oxygen at a higher level than prescribed, and the oxygen tubing was not labeled as required. The nurse confirmed that the oxygen level was changed without updating the clinical record, and there was no order to change the oxygen tubing weekly. Resident R72, with acute respiratory failure and COPD, had an order for weekly oxygen tubing changes and labeling, but the tubing was not labeled during observation. Resident R1, who has a tracheostomy and is not cognitively intact, was observed without suctioning equipment at the bedside during trach care, leading to a delay in care when the nurse had to leave to retrieve necessary supplies. The Director of Nursing confirmed that suction supplies should be readily available at the bedside for residents with tracheostomies. Resident R51, with respiratory failure and COPD, was found in the dining room with an empty oxygen tank and no staff present, despite having an order for continuous oxygen therapy. The LPN confirmed the resident was without adequate oxygen therapy. These deficiencies indicate a failure to adhere to physician orders and facility policies, compromising the respiratory care of the residents involved.
Plan Of Correction
A - Resident R1 suction machine obtained at the time identified. E20 was educated at the time this was reported. R51 oxygen tank was exchanged for a new tank at the time noted empty. E19 educated on ensuring 02 tanks are full when a resident is taken to the dining room. R10 obtained physician order to change tubing and tubing was changed. R72 oxygen tubing was changed at the time identified. B - Audit of all residents who require suctioning to ensure they have a suction machine at bedside and audit of all who require oxygen to ensure they have orders to change tubing weekly. C - All nursing staff educated on weekly oxygen tubing change orders, ensuring suction machine is present at bedside for residents requiring suctioning, and ensuring oxygen tanks are not empty when in use by resident in dining room. D - Weekly x 4 then monthly x 2 audits by DON or designee to ensure oxygen tubing has weekly change orders and is changed weekly, residents in dining room who use oxygen do not have empty tanks, and a suction machine is present at bedside for those who require suction.