Failure to Maintain Sanitary Respiratory Care Equipment and Adhere to Change Schedules
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to physician orders and facility policy regarding respiratory care for five residents requiring oxygen therapy or nebulizer treatments. Multiple residents were observed using oxygen tubing and nasal cannulas that were not changed according to the prescribed weekly schedule, with tubing dated well beyond the required change interval. Documentation on the Treatment Administration Record (TAR) indicated that tubing changes were recorded as completed, but direct observation showed otherwise. Additionally, nebulizer equipment was improperly stored, with one resident's nebulizer mask and tubing left unlabeled and on a dresser, and another resident's oxygen cannula left wrapped around a cylinder caddy handle instead of being stored in a protective bag as required by policy. Residents involved had significant respiratory diagnoses, including acute and chronic respiratory failure, hypoxia, COPD, metastatic lung cancer, and end-stage emphysema, necessitating strict adherence to respiratory care protocols. Staff interviews revealed inconsistent understanding and application of the facility's policy, with some staff stating tubing was changed every two weeks despite orders and documentation indicating weekly changes. The facility's own policy required nasal cannulas to be changed every two weeks and stored in a plastic bag when not in use, and nebulizer parts to be cleaned and stored properly, but these procedures were not consistently followed.