Failure to Properly Store and Label Respiratory Equipment and Clarify Physician Orders
Penalty
Summary
Surveyors identified that the facility failed to properly label, date, and store respiratory equipment in a sanitary manner for a resident requiring respiratory care. During observation, respiratory equipment was found draped over the resident's nightstand and wheelchair, left open to air and in one instance touching the bathroom floor, rather than being stored in a bag as required. Staff interviews confirmed that the equipment should have been labeled, dated, and stored in a bag labeled with the resident's information when not in use, but this was not done. The resident's care plan and physician orders included instructions for proper storage and dating of the equipment, but these were not followed. Additionally, the facility failed to clarify a physician's order related to the resident's respiratory care. Staff acknowledged that the order to wean the resident from the respiratory device should have been clarified to include specific details, but this was not done. Review of facility policies revealed there was no written protocol addressing the proper dating and storage of the respiratory equipment, and the existing oxygen administration policy did not address these requirements. The resident involved had relevant medical diagnoses and was assessed as needing respiratory care, as documented in the admission record and Minimum Data Set.
Plan Of Correction
Respiratory/Tracheostomy Care and Suctioning CFR(s): 483.25(i) 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 88 no longer resides in the facility. On 04/17/25, The Assistant Director of Nursing replaced the x Only 26, labeled and dated it appropriately. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee in-serviced all licensed nursing staff on ensuring oxygen tubing is stored in bags when not in use and to replace it if it is observed on the floor or not in a bag. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 10 residents with NJ Ex Order 26. 4B1 to make sure it is stored appropriately. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.