Failure to Provide Adequate Ventilator Weaning Due to Lack of Trained Staff
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required mechanical ventilation and had physician orders to be weaned from the ventilator at night in two-hour increments under close supervision by respiratory therapy. The resident, who had diagnoses of acute respiratory failure and tracheostomy status, was not aware of any progress in weaning from the ventilator. Interviews with staff confirmed that there was insufficient respiratory therapy coverage at night, and floor nurses were not trained to perform ventilator weaning. As a result, the resident was not making progress in being weaned from the ventilator due to the lack of qualified staff during the required times. Review of staff schedules corroborated that no respiratory therapy staff were scheduled on several nights when the weaning process was ordered to occur. The facility's policy required that appropriate staff be trained and maintain competency in the use of mechanical ventilation, but this was not met. The deficiency was identified during a complaint investigation and was noted as continued non-compliance from previous surveys.