Failure to Provide Proper Respiratory Care and Equipment Maintenance
Penalty
Summary
A resident with a history of cerebral infarction, acute respiratory distress syndrome, respiratory failure with hypoxia, chronic obstructive pulmonary disease, and obstructive sleep apnea was observed to have deficiencies in the provision of respiratory care. Multiple observations revealed that the resident's oxygen concentrator humidifier was empty, not dated, and contained a dry white substance. The nasal cannula was also not dated, and there was no indication that it had been changed as required. These issues persisted over several days, with the humidifier remaining empty during repeated checks. Interviews with nursing staff and CNAs revealed confusion and inconsistency regarding responsibility for oxygen equipment maintenance, including changing and labeling cannulas and humidifiers. Staff provided conflicting information about schedules for changing tubing and humidifiers, and there was a lack of clarity about which staff members were responsible for these tasks. The DON confirmed that humidification should be used for residents on higher oxygen flow rates and that equipment should be labeled and changed regularly, but acknowledged uncertainty about current practices and adherence to protocols.