Failure to Label and Replace Respiratory Equipment per Protocol
Penalty
Summary
The facility failed to ensure proper labeling and timely replacement of respiratory care equipment for two residents. For one resident with end stage renal disease and anemia, an oxygen concentrator with a nasal cannula and humidifier was observed at the bedside. The nasal cannula was dated from the previous month, and the humidifier was not labeled with any date. The resident reported that the oxygen machine had not been used in the past two weeks. During an interview, a registered nurse confirmed that both the nasal cannula and humidifier should be labeled and changed at least weekly, and acknowledged that failure to do so could potentially cause infection. For another resident with chronic obstructive pulmonary disease and congestive heart failure, a review of records showed a physician's order for twice-daily Budesonide inhalation via nebulizer. The resident's care plan indicated a risk for infection, and medication administration records confirmed regular use of the nebulizer. During observation, the nebulizer tubing was found to be dated from eleven days prior, exceeding the facility's protocol of changing tubing every seven days. The mask attached to the tubing was dated more recently. A licensed vocational nurse stated that the tubing should have been changed according to the weekly schedule but was not. Facility policy and procedure for administering medications through a handheld nebulizer specified that equipment and tubing must be changed every seven days and stored in a plastic bag with the resident's name and date. The failure to follow these protocols for both residents resulted in deficiencies related to the safe and appropriate provision of respiratory care.