Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required supplemental oxygen or noninvasive ventilation therapies. Facility policy required that used cannulas, masks, and tubing be stored in a labeled plastic bag off the floor when not in use. For one resident with coronary artery disease, hypertension, and diabetes, the BiPAP mask was observed sitting on the nightstand and not stored in a plastic bag as required. A second resident with peripheral vascular disease, depression, and sleep apnea also had their BiPAP mask left out on the nightstand without a storage bag. In both cases, nursing staff confirmed the equipment was not properly stored according to policy. A third resident with high blood pressure, COPD, and PTSD had a nasal cannula observed lying on the floor and a CPAP mask left on top of the machine, rather than stored in a labeled plastic bag. The nasal cannula was later moved off the floor, but staff confirmed it had not been properly stored. Additionally, this resident's care plan did not include interventions or a plan of care for oxygen or CPAP therapy, as confirmed by the Registered Nurse Assessment Coordinator. These failures were identified through observations, staff interviews, and clinical record reviews.