Failure to Provide Safe and Appropriate Respiratory Care for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents who were dependent on ventilators with tracheostomy tubes. For one resident, the ventilator circuit was not effectively monitored, resulting in the resident being found disconnected from the ventilator and unresponsive. Documentation showed that after being readmitted, the resident was alert and oriented, but there was no evidence of required ventilator checks or suctioning as per physician orders and facility policy. The resident was later found unresponsive, disconnected from the ventilator, and required manual ventilation and a Code Blue response. The ventilator alarm log was found to have inaccurate time settings, and it was unclear if the alarm sounded during the incident. Interviews revealed that there was no dedicated respiratory therapist (RT) in the facility, and the RT assigned was also responsible for the acute care unit, leading to lapses in monitoring and care. For the second resident, the facility failed to ensure that policies and procedures for respiratory care were followed when oxygen therapy and parts of the disposable ventilator circuit were replaced and rinsed by a non-qualified staff member. The resident, who had severely impaired decision-making capacity, experienced a sudden change in condition, turning blue and requiring an increase in FiO2. During the event, a CNA replaced the HME filter and rinsed the T-adapter, and also increased the FiO2, actions that were outside the CNA's scope of practice. The RT was not present at the time, and the nurse on duty did not immediately intervene, instead asking the CNA to assist. The RT manager confirmed that CNAs were not permitted to perform these tasks and that the T-adapter should not have been rinsed. Both incidents were compounded by the lack of a dedicated RT in the facility, with RTs being shared with the acute care hospital. This led to delays in care and interventions, as well as non-compliance with facility policies and procedures regarding ventilator management, suctioning, and equipment handling. Documentation and interviews confirmed that required assessments, monitoring, and interventions were not consistently performed or documented, directly contributing to the deficiencies identified.