Failure to Provide Required Respiratory Emergency Equipment and Treatments
Penalty
Summary
Surveyors identified multiple deficiencies related to the provision of safe and appropriate respiratory care for residents with tracheostomies and other respiratory needs. Several residents with tracheostomies did not have the required emergency equipment, such as Ambu bags and replacement tracheostomy tubes of the same size and one size smaller, at their bedside as ordered by physicians. In several cases, staff were unable to explain the absence of this equipment, and unit managers confirmed the missing supplies. For example, one resident with a tracheostomy had neither an Ambu bag nor the required replacement tracheostomy tubes at the bedside, and another had only partial supplies, lacking the smaller size tube as ordered. The facility's own policy required these supplies to be present and visible at the bedside, but observations revealed this was not consistently followed. In addition to missing emergency tracheostomy supplies, there were failures in the labeling and maintenance of respiratory equipment. For one resident, oxygen tubing, tracheostomy masks, and suction canisters were not labeled with the date of last change, and the required replacement tracheostomy set of one size down was not available due to supply issues. The Central Supply Director acknowledged not having ordered the necessary size for an extended period, and the DON confirmed the lack of appropriate supplies. Other residents were also found to have incomplete or incorrect emergency tracheostomy kits, with missing inner or outer cannulas or incorrect sizes, contrary to physician orders and facility policy. There were also deficiencies in the provision and documentation of respiratory treatments. One resident with an order for BiPAP therapy experienced a significant delay in receiving the device, and once delivered, staff were unclear on how to set it up or adjust settings. Documentation in the medical record indicated that care tasks related to the BiPAP were marked as completed even before the device was available, and refusals or limited use by the resident were not documented. Staff interviews revealed confusion about responsibilities for ordering and setting up respiratory equipment, and the facility lacked a specific policy for respiratory care beyond oxygen use.