Failure to Change and Label Respiratory Equipment as Required
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents requiring respiratory support. For one resident with a history of pericardial effusion, COVID-19, and dysphagia, the suction canister was not labeled with the date it was last changed, and the suction tubing in use was dated several months prior, indicating it had not been replaced within the required seven-day interval. Both the Director of Staff Development and the Assistant Director of Nursing confirmed that respiratory supplies should be changed and dated weekly, but the supplies in the resident's room did not meet these requirements. The facility's policy also required weekly changes and proper labeling of suction equipment to minimize infection risk. For another resident with chronic respiratory failure and dependence on supplemental oxygen, the oxygen tubing in use was not labeled with the date and time it was last changed. Observations and interviews with facility staff, including the Director of Rehabilitation and the DON, confirmed that the tubing lacked proper labeling and that staff are responsible for weekly changes and labeling. The facility's policy specified that oxygen cannula and tubing should be changed every seven days or as needed, and that staff should check labels to ensure compliance. These deficiencies were identified through observation, interview, and record review, and were confirmed by multiple staff members who acknowledged the requirements for changing and labeling respiratory equipment. The lack of adherence to these protocols was directly observed in both residents' rooms, and facility policies reviewed by surveyors supported the need for weekly changes and proper documentation.