Failure to Provide Safe and Timely Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for three residents who required respiratory support. For one resident with a history of morbid obesity, acute pulmonary edema, chronic congestive heart failure, cardiomegaly, and sleep apnea, there was no protocol or physician order in place for cleaning or replacing the non-invasive ventilation support tubing and mask. The resident's care plan and medical records lacked documentation of any cleaning or replacement of this equipment, despite regular use. Multiple LPNs assigned to the resident confirmed that they only cleaned the mask if visibly soiled and never cleaned or replaced the tubing, and there was no documentation of these actions. The DON and CNO acknowledged the absence of orders and documentation for cleaning or replacing the equipment, and the nurse practitioner confirmed that a protocol should have been implemented. For two other residents receiving oxygen therapy, the facility did not ensure timely changing and labeling of oxygen tubing and humidification bottles. One resident, who used oxygen as needed, had a humidifier bottle that was not changed according to the weekly schedule, as confirmed by both observation and staff interviews. The DON verified that the bottle should have been changed and was not. The second resident, with diagnoses including acute respiratory failure with hypoxia and emphysema, had an empty and undated humidifier bottle and nasal cannula tubing. Staff confirmed that both the tubing and bottle should have been changed weekly and labeled with the date, but this was not done. Interviews with staff, including LPNs and the DON, consistently revealed a lack of adherence to facility policy and procedure regarding the cleaning, replacement, and documentation of respiratory care equipment. The facility's own policies required regular cleaning and replacement of respiratory equipment, but these protocols were not followed or documented for the residents reviewed.