Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring such care, as evidenced by direct observation, interviews, and record review. For one resident with a tracheostomy, an LVN did not perform hand hygiene at multiple required points during the tracheostomy care procedure. The LVN donned gloves and a gown without first sanitizing her hands, removed the old stoma dressing and inner cannula, and then proceeded to open and handle sterile supplies without hand hygiene. During the process, the LVN contaminated the sterile field by touching a non-sterile saline bottle and failed to maintain sterile technique throughout the procedure. The LVN acknowledged awareness of the correct sterile procedure and hand hygiene requirements but stated she was nervous and forgot to sanitize her hands. The facility's policy and staff interviews confirmed that tracheostomy care should be performed using sterile technique with hand hygiene before and after glove changes. Another resident was observed receiving continuous oxygen therapy via nasal cannula, but there was no physician order specifying the need for oxygen or the number of liters to be administered. The resident's care plan and physician order summary did not reflect any order for oxygen therapy, despite the resident stating she had been receiving oxygen since admission. Staff interviews confirmed that a physician order should have been in place prior to administering oxygen, and the absence of such an order was acknowledged as a failure to follow protocol. Both deficiencies were confirmed through interviews with nursing staff and the DON, who stated that proper procedures were not followed. The facility's policies on tracheostomy care and oxygen administration both require adherence to professional standards, including sterile technique and physician orders for respiratory treatments. The observed failures placed residents at risk for respiratory infections and incorrect oxygen administration.