Failure to Provide Safe and Appropriate Respiratory Care and Maintain Infection Control
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who required oxygen therapy or CPAP support. For two residents, staff did not ensure oxygen was administered as per physician orders and failed to store nasal cannula tubing in a sanitary manner. One resident was observed with a nasal cannula left on the bed and not in a plastic bag, while another had the tubing wrapped around a bed rail. In both cases, the oxygen concentrator was running, but the residents were not using the oxygen as ordered, and there was no documentation of communication with the physician regarding changes in oxygen use or need. Another resident using a CPAP machine did not have a care plan addressing the use of the device, and there was no physician's order for the cleaning and maintenance of the CPAP as directed by the manufacturer's guidelines. The CPAP mask was left on top of a drawer, and the tubing was stored in a plastic bag, but staff could not provide the user guide for the device and confirmed that cleaning instructions were not being followed or documented. Additionally, a resident receiving continuous oxygen therapy was observed with oxygen tubing touching the floor, which was verified by the infection preventionist. The facility's policies required proper storage and regular changing of oxygen tubing and cannulas, as well as adherence to infection control practices, but these were not consistently followed for the residents reviewed.