Failure to Document and Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required oxygen therapy and nebulizer treatments. Specifically, the facility did not ensure that nebulizer masks and oxygen cannulas were changed and documented according to physician orders and facility policy. Observations revealed that one resident's nasal cannula appeared dirty and there was no documentation in the electronic health record (EHR) indicating when it had last been changed. Interviews with the resident and her roommate provided conflicting accounts of when the cannula was last replaced, and staff interviews confirmed that the process for changing and documenting respiratory equipment was inconsistent. Record reviews for the three residents showed active orders for regular changing of oxygen and nebulizer tubing, masks, and cannulas, with specific instructions for weekly changes and documentation in the EHR. However, there was no evidence in the records that these changes were consistently performed or documented. Staff interviews revealed a lack of clarity regarding responsibility and routine for changing respiratory equipment, with some staff stating it should be done weekly, typically on Sundays, and others unsure of the exact process. The facility was also in the process of transitioning to a new EHR system, which contributed to gaps in documentation. The facility's own policy required weekly changing and documentation of oxygen and nebulizer tubing and masks by the nursing department. Despite this, the required documentation was missing, and direct observation confirmed that at least one resident was using respiratory equipment that had not been changed as required. This failure to follow established protocols and document care placed residents at risk for infection, as noted by staff during interviews.