Failure to Provide Safe and Appropriate Respiratory Care and Adhere to Infection Control Practices
Penalty
Summary
The facility failed to provide respiratory care services as ordered by the physician and did not adhere to infection control and prevention practices for two residents requiring respiratory support. For one resident with autonomic nervous system disorder, Parkinson's disease, and borderline personality disorder, the care plan required weekly changes of disposable oxygen tubing and related supplies. However, observations revealed that the oxygen concentrator tubing and bubbler had not been changed as scheduled, with the last change documented over a week prior. The responsible nurse assigned the task to CNAs and only spot-checked a few rooms, failing to verify that the supplies for this resident had been changed. In another instance, a resident with congestive heart failure and chronic respiratory failure with hypoxia was observed when a CNA dropped the oxygen cannula tubing on the ground while filling the resident's portable oxygen unit. The CNA then picked up the tubing and reconnected it to the oxygen unit without replacing it, contrary to infection control protocols. The CNA acknowledged the error, and the charge nurse confirmed that the tubing should have been replaced before reuse.