Failure to Maintain and Document Safe Respiratory Care Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for several residents requiring oxygen therapy and nebulizer treatments. For four residents, oxygen and nebulizer tubing were found to be unlabeled and undated, contrary to facility policy which requires weekly changing, labeling, and dating of such equipment. In addition, nebulizer masks were observed to be stored improperly, either uncovered in bedside drawers or on top of bedside tables, rather than in a manner that would maintain cleanliness and prevent contamination. These deficiencies were observed during direct inspection and confirmed through interviews with nursing staff, who were unable to provide reasons for the lapses or confirm when the equipment was last changed. For one resident with chronic obstructive pulmonary disease, asthma, and congestive heart failure, the facility failed to document oxygen saturation levels every shift as required by physician order. Review of the electronic medical record revealed that oxygen saturation was not consistently recorded for every shift, and the documentation system lacked a prompt to ensure compliance with the order. The Director of Nursing Services (DNS) acknowledged that the absence of documentation made it impossible to verify that the resident's oxygen saturation remained above the physician-ordered threshold on every shift. Interviews with nursing staff and the DNS revealed a lack of clarity regarding responsibility for changing, labeling, and dating respiratory equipment, as well as uncertainty about whether staff had received adequate education on these procedures. Facility documentation and physician orders were also found to be lacking in directives for the maintenance of respiratory equipment. The facility's own policy requires oxygen tubing to be dated and changed weekly, but this was not consistently implemented or documented for the residents reviewed.