Failure to Date Respiratory Equipment for Residents with Tracheostomies and Ventilators
Penalty
Summary
The facility failed to ensure that respiratory equipment, including ventilator circuits, tracheostomy collars, and oxygen tubing, was properly dated to confirm timely changes as required by facility policy and physician orders. During observations, it was noted that three residents with significant respiratory needs—such as chronic respiratory failure, tracheostomy, ventilator dependence, and severe cognitive or physical impairments—had respiratory equipment in use that was not labeled with the date of last change or the initials of the responsible staff. Interviews with the respiratory therapist and registered nurse confirmed that the equipment was not dated, and that it was the responsibility of the respiratory therapy department to ensure proper labeling and timely changes. Record reviews for these residents showed that their care plans and physician orders required respiratory equipment to be changed at specific intervals, typically every thirty or ninety days, and as needed. Facility policy also mandated that oxygen setups be labeled with the date and staff initials at the time of change. The lack of dating on the equipment meant there was no way to verify that changes were occurring as required, potentially compromising infection control practices for these residents, all of whom were highly dependent on staff for their care.