Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three residents. For one resident with a history of congestive heart failure, COPD, and pulmonary hypertension, the oxygen concentrator was observed to be turned off on two separate occasions while the resident was wearing a nasal cannula and had orders for PRN oxygen for shortness of breath. Documentation showed that the resident had received PRN oxygen for shortness of breath, but during observations, the oxygen concentrator was not delivering supplemental oxygen as required. Staff interviews confirmed that the concentrator should have been turned on when the nasal cannula was in use, and the facility's policy required oxygen to be administered at the prescribed rate with verification of flow. Another resident, with diagnoses including UTI, E. coli infection, and Alzheimer's disease, was found to have nebulizer tubing and mask on the floor in their room. Staff acknowledged that the tubing and mask should not be on the floor due to the risk of contamination, and that the equipment should be stored in a plastic bag, labeled, and kept off the floor. The facility's policy and staff interviews confirmed that using contaminated respiratory equipment could lead to respiratory infections. A third resident, with heart failure, COPD, and Alzheimer's disease, was observed with nasal cannula oxygen tubing touching the floor. The tubing was also overdue for replacement according to the facility's policy, which required weekly changes. Staff interviews indicated that the tubing should have been stored properly and not allowed to touch the floor to prevent infection. The facility's policy specified that all oxygen delivery items are for single resident use, must be changed weekly or when soiled, and stored in a labeled plastic bag at the bedside.