Failure to Adhere to Respiratory Tubing Change Protocols
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care in accordance with professional standards of practice for two residents who required ventilator or tracheostomy care. For one resident with severe cognitive impairment and total dependence for activities of daily living, the tracheostomy tubing in use was observed to be dated more than three weeks prior, despite facility policy requiring tubing changes every seven days or as needed. There was no physician's order specifying the frequency of tubing changes for this resident, and staff interviews confirmed that tubing was changed on a set weekly schedule, not necessarily aligned with policy or physician orders. For another resident, also severely cognitively impaired and dependent on staff, ventilator tubing was observed to be in use beyond the weekly change interval specified in the physician's order. The care plan for this resident directed staff to keep respiratory equipment clean and change disposable equipment per facility policy, but the observed practice did not align with these directives. Interviews with staff and the DON confirmed that respiratory tubing should be changed per physician order or, if absent, per facility policy, but this was not consistently followed.