Failure to Provide Timely and Appropriate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and maintenance for four residents who required respiratory therapy. For each resident, physician orders specified the use of oxygen therapy, including the prescribed flow rate, and required weekly changes of humidifier bottles and oxygen cannula/tubing, typically on Sunday night shifts or as needed. However, record reviews and direct observations revealed that these supplies were not changed as ordered. For example, humidifier bottles and oxygen tubing were found to be undated or dated well before the most recent scheduled change, and in one case, a humidification bottle was found empty. Additionally, the facility did not provide a copy of its Respiratory Therapy policy when requested. The residents involved had significant respiratory diagnoses, including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and respiratory failure with hypoxia. Despite clear care plans and physician orders outlining the need for regular maintenance and monitoring of respiratory equipment, staff did not consistently follow these protocols. The lack of timely equipment changes and proper documentation was observed for all four residents reviewed, indicating a systemic failure to adhere to prescribed respiratory care procedures.