Failure to Follow Respiratory Care Policies and Documentation Requirements
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents by not adhering to its own policies and professional standards of practice. Specifically, staff did not follow proper tracheostomy care procedures for one resident, including failing to perform required pre- and post-respiratory assessments. Additionally, staff did not obtain or document necessary written orders for respiratory treatments and oxygen therapy for multiple residents. There were also failures to perform and document pre- and post-treatment vital signs and lung sound assessments when administering nebulizer treatments, as required by facility policy. Further deficiencies included improper storage and maintenance of respiratory equipment and supplies for several residents receiving oxygen therapy. In one instance, a resident reported not receiving a breathing treatment as needed and indicated that treatments were only provided upon request. Documentation reviewed showed that staff were administering respiratory medications but were not consistently documenting required assessments or following established protocols for equipment labeling and maintenance.