Failure to Maintain and Document Proper Respiratory Care and Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents by not adhering to its own policies and procedures regarding the maintenance and administration of respiratory equipment and therapy. Multiple residents were found with respiratory equipment, such as nebulizer masks, oxygen tubing, and storage bags, that had not been changed or labeled according to the facility's policy, which required weekly changes and proper labeling for infection control. For example, storage bags for nebulizer masks for several residents were observed to be dated well beyond the required seven-day change interval, and some were not labeled with the resident's name or the date. In addition, a nasal cannula was found improperly stored, hanging from a portable oxygen tank instead of being kept in a clean bag, and some respiratory bags were not replaced or labeled as required. Further deficiencies were identified in the administration and documentation of oxygen therapy. One resident was observed receiving oxygen therapy without a physician's order or documentation in the Medication Administration Record (MAR), contrary to the facility's policy that oxygen is a drug requiring a physician's order and proper documentation. Staff interviews confirmed the absence of the required order and documentation, and staff were unable to provide a reason for the administration of oxygen to the resident. Other residents had physician orders for respiratory treatments, but the associated equipment was not maintained or changed as per policy, and staff acknowledged these lapses during interviews. The facility's own policies, as reviewed by surveyors, specified that respiratory equipment should be changed weekly and as needed, and that oxygen therapy must be ordered by a physician and documented in the resident's file. Despite these clear guidelines, observations and staff interviews revealed that these procedures were not consistently followed, leading to deficiencies in infection control and proper respiratory care for multiple residents. The Director of Nursing and other administrative staff acknowledged these findings during interviews.