Failure to Provide Required Respiratory Care and Supplies at Bedside
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy, as required by physician orders and the resident's care plan. Specifically, the resident was to have a spare tracheostomy tube and ambu bag at bedside, but during observation, these supplies were not present. When staff were asked to locate the correct size trach kit, it took over 15 minutes to find it in a supply closet rather than at the bedside, as required. The respiratory therapist acknowledged the error in ordering the wrong size trach and confirmed the supplies were not readily available as directed. Further review revealed discrepancies in the documentation and understanding of the trach size, with the respiratory therapist admitting to confusion over the sizing and the care plan reflecting incorrect information. Interviews with staff indicated a lack of clarity regarding who was authorized to replace the trach tube, and the facility's own procedures required verification of the correct size and availability of two replacement trachs at bedside. The DON confirmed the delay in locating the correct supplies and agreed that the spare trach should have been at bedside. Additionally, another resident with an order for continuous oxygen was observed without oxygen in place, and the oxygen concentrator was turned off. The LPN confirmed the resident was not receiving oxygen as ordered and adjusted the settings after the deficiency was identified. These findings demonstrate failures in adhering to physician orders and care plans for respiratory care for both residents.