Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring respiratory support. For one resident, the nebulizer mask, tubing, and bag were not changed weekly as ordered by the physician, with equipment at the bedside dated beyond the required change interval. Both a registered nurse and a respiratory care practitioner confirmed that the equipment should have been changed and properly labeled, but it was not, as evidenced by the dates observed on the items. For another resident with a tracheostomy and on mechanical ventilation, the facility did not ensure the correct emergency tracheostomy set was available at the bedside. Instead of a cuffed tracheostomy set as ordered, an uncuffed set was provided. Additionally, the suction device (Yankauer catheter) was not changed weekly as per physician's orders, with an outdated device found at the bedside. Staff interviews confirmed these lapses in following physician orders and facility policy.