Failure to Properly Store, Label, and Document Respiratory Care Equipment and Monitoring
Penalty
Summary
Facility staff failed to ensure proper storage and labeling of respiratory equipment and did not consistently document oxygen saturation levels as ordered for a resident with chronic obstructive pulmonary disease and acute hypoxic respiratory failure. Observations revealed that the resident's oxygen humidifier bottle was repeatedly found undated and unlabeled on multiple occasions. The BiPAP tubing nose piece and nasal cannula were observed not properly stored, with the nasal cannula found laying on the floor several times. Staff interviews confirmed that the equipment should have been labeled, dated, and stored in a clean manner, such as in a clear plastic bag when not in use, but these practices were not followed. Additionally, review of the resident's medical records showed missing documentation of required oxygen saturation checks during several night shifts, despite a physician's order to monitor and record these values each shift. Staff acknowledged the expectation to document oxygen saturation per the physician's order and to maintain proper storage and labeling of respiratory equipment, but these procedures were not consistently implemented for the resident.