Failure to Follow Respiratory Care Protocols and Physician Orders
Penalty
Summary
Two deficiencies were identified during the review of respiratory care provided to residents. For one resident with hemiplegia, hemiparesis, dementia, gastrostomy, and dysphagia, there was an order to swab/suction every shift as appropriate, and a separate order to suction as needed for excessive secretions. However, observation revealed that suction equipment, including a yankauer, suction tubing, and a collection canister, remained at the bedside well beyond the facility's policy for single-use items. The equipment was dated several days prior and had not been discarded or replaced after use, contrary to the facility's protocol and infection control policy. Staff interviews confirmed that the equipment should have been changed after each use to prevent contamination and infection, but this was not done. A second deficiency involved another resident with diagnoses including type 2 diabetes, cerebral infarction, and dependence on oxygen. This resident was observed receiving oxygen therapy at two liters per minute, but a review of the medical record revealed there was no physician's order for the administration of oxygen. Staff confirmed that the resident was receiving oxygen without a doctor's order, which was not in accordance with the facility's policy that requires a physician's order for oxygen therapy. The DON also confirmed that the policy mandates administration of oxygen only per physician orders. Both deficiencies were substantiated through direct observation, record review, and staff interviews. The facility failed to follow its own policies regarding the safe administration of respiratory care, specifically in the areas of equipment management and ensuring proper physician authorization for oxygen therapy.