Inadequate Respiratory Supply for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to maintain an adequate supply of heat and moisture exchange (HME) devices for all 14 residents with tracheostomy tubes who were dependent on mechanical ventilators. On 6/29/2025, there were only 8 HMEs available for 14 residents, and this shortage persisted until the supply was replenished on 7/2/2025. According to the facility's policy and procedure, HMEs are required to be changed every 24 hours or when soiled, but due to the insufficient supply, this standard was not met for any of the affected residents during the shortage period. All 14 residents involved had diagnoses including respiratory failure and were dependent on others for most activities of daily living, as well as on oxygen therapy, suctioning, tracheostomy care, and ventilator support. The Respiratory Therapist Lead and Assistant Director of Nursing both confirmed that the available supply was inadequate to meet the needs of the residents, and that the facility's policy regarding HME changes could not be followed during the shortage. The shortage was attributed to a delay in delivery from the respiratory supply vendor, despite timely ordering by facility staff.