Oxygen Tubing Found on Floor for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents who required ventilator and oxygen support. For both residents, observations revealed that oxygen tubing connected to their ventilators was resting on the floor. Resident 29, who was in a persistent vegetative state with chronic respiratory failure, tracheostomy, and under hospice care, was observed with oxygen tubing touching the floor in their room. Resident 63, who was ventilator-dependent with chronic respiratory failure, COPD, ALS, and had mental capacity, was also observed with oxygen tubing on the floor. Both residents had care plans with goals to remain free of infection, and physician orders for oxygen therapy and ventilator support. During interviews, the respiratory therapist acknowledged the tubing was on the floor and agreed it could be an infection control issue, stating the tubing would be replaced. The infection preventionist and DON also confirmed that oxygen tubing touching the floor constituted an infection control problem. The facility's infection control policy required maintaining a safe and sanitary environment to prevent and control infections, and staff were to be trained on these practices. Despite these policies, the observed practice of allowing oxygen tubing to rest on the floor represented a failure to adhere to infection control standards.