Failure to Date and Change Respiratory Equipment as Required
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that nasal cannulas, oxygen humidification containers, and nebulizer administration equipment were properly dated for five residents who required respiratory support. Observations revealed that multiple residents had oxygen and nebulizer equipment in use without any date labels, despite physician orders and facility policy requiring weekly changes and dating of this equipment. In several cases, the care plans for residents receiving oxygen therapy did not include documentation of oxygen use, and treatment administration records did not reflect that equipment changes had occurred as ordered. For example, one resident with diagnoses including pulmonary hypertension and heart failure had orders for oxygen therapy and weekly tubing changes, but their oxygen tubing, humidification container, and nebulizer equipment were not dated during multiple observations. Another resident with chronic obstructive pulmonary disease and acute respiratory failure had a humidification bottle dated from a previous week and undated nasal cannula tubing. Additional residents were observed with undated oxygen tubing or equipment, and in one case, a nebulizer mouthpiece and tubing were dated over a month prior to the observation, with no documentation of recent changes as required by physician orders. Interviews with nursing staff, including LPNs and an RN, confirmed that the expectation was for all oxygen and nebulizer equipment to be changed and dated weekly, with the night shift responsible for this task. The DON also acknowledged that equipment for some residents was not dated as required. The facility's own policy specified that oxygen use should be care planned, humidifiers labeled with the date opened, and tubing changed and dated weekly, but these procedures were not consistently followed for the residents reviewed.