Failure to Provide Safe and Appropriate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care for multiple residents, as evidenced by a lack of physician orders, incomplete care planning, and improper management of respiratory equipment. For example, one resident was administered oxygen without a physician's order or a corresponding care plan, and suctioning was performed without an order. Observations revealed that respiratory equipment such as suction canisters and catheters were undated, unlabeled, and not stored in set-up bags as required by facility policy. Another resident was found to be receiving oxygen at a rate higher than prescribed by the physician, with undated nasal cannula tubing and a set-up bag that was not changed weekly. Additional residents had respiratory therapy equipment, such as nebulizer masks and oxygen tubing, that were not dated or changed according to the facility's infection control policies. In several cases, the required set-up bags for storing respiratory equipment when not in use were missing, and equipment was not labeled with the resident's name or date as required. Interviews with staff, including LVNs, the Central Supply Manager, and the DON, confirmed that respiratory supplies were not consistently labeled, changed, or stored according to policy. The facility's own policies required weekly changes and proper labeling of respiratory equipment, but these procedures were not followed for several residents. These failures were observed across multiple residents and confirmed through staff interviews and medical record reviews.