Failure to Maintain and Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not ensuring that oxygen tubing, nebulizer machines, and nebulizer tubing were properly maintained and changed as required. Observations revealed that one resident's nebulizer machine was stained, dusty, and placed on the floor, with the face mask left uncovered on a heating unit and not changed since the date marked over a month prior. Another resident's oxygen concentrator was found with humidity water and nasal cannula tubing that had not been changed for nearly two months. A third resident was observed using a nebulizer mask with mist spraying into the air, with the oxygen concentrator on the floor and humidity water not changed for almost a month. In all cases, the equipment was not maintained according to the facility's expected weekly change schedule. Interviews with staff, including an LPN and the DON, confirmed that the respiratory equipment should have been changed weekly, but there was no policy available to support this practice. The clinical records for the residents indicated diagnoses such as chronic obstructive pulmonary disease, dementia, morbid obesity, encephalopathy, and neurogenic bladder, with physician orders specifying the frequency for changing respiratory equipment. Despite these orders, the facility did not ensure compliance, resulting in the cited deficiency.