Failure to Provide Appropriate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents as required by facility policy and physician orders. For one resident with diagnoses including anemia, heart failure, and dysphagia, the physician order specified nightly use of a CPAP machine, with instructions for cleaning and storage. However, the order did not include the CPAP settings or a diagnosis, and the resident's baseline care plan lacked interventions related to CPAP use. Observations over several days showed the resident's CPAP mask was repeatedly left out on the bed or dresser, not stored in a bag as required by policy. Staff interviews confirmed the improper storage and the absence of a baseline care plan for CPAP care. For another resident with pneumonia, congestive heart failure, and emphysema, the oxygen tubing in use was not labeled with a date, contrary to facility policy that requires dating and weekly changing of such equipment. This was confirmed by staff during interviews. Facility leadership acknowledged the failure to provide appropriate respiratory care for both residents.