Failure to Maintain and Change Respiratory Equipment per Policy
Penalty
Summary
The facility failed to provide adequate respiratory care and maintain respiratory equipment in a sanitary manner for four of six sampled residents who utilized respiratory equipment. Facility policy required oxygen humidifiers to be changed every seven days and as needed, and nebulizer equipment to be changed daily. However, observations revealed that humidification bottles on oxygen concentrators for multiple residents were not dated, and nebulizer tubing and oxygen tubing were not changed according to policy. For example, one resident's nebulizer tubing was dated nine days prior to observation, and another resident's oxygen tubing was dated eleven days prior. In one case, a resident's oxygen tubing was not dated at all. Additionally, a resident reported that her oxygen humidifier bottle was very low and had not been changed since a specific date, which was confirmed by observation of an almost empty humidifier bottle and a dated bag indicating it had not been changed in over two weeks. Interviews with the Director of Nursing confirmed that the facility's policy was not followed, as equipment was not changed at the required intervals. These deficiencies were identified through review of clinical records, resident and staff interviews, and direct observation.