Failure to Ensure Proper Respiratory Care and Safety Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents requiring such care, as evidenced by two specific incidents involving six residents reviewed for respiratory care. In the first incident, a male resident with a history of respiratory failure and chronic obstructive pulmonary disease was observed with his nebulizer breathing mask left unbagged on his side table after use. The resident was cognitively intact and receiving inhalation treatments as ordered. Staff interviews confirmed that the mask should have been bagged when not in use to prevent respiratory infections, but this was not done. In the second incident, a female resident admitted with respiratory failure and requiring continuous oxygen via tracheostomy did not have an "Oxygen in Use" sign posted outside her room upon admission. Staff acknowledged that the sign was not placed as required, which is necessary to alert staff and visitors to the presence of oxygen in the room. The facility's own policy mandates that such a sign be posted at the entrance when oxygen is in use. Interviews with nursing staff, the ADON, and the Administrator confirmed that the expected practice is to bag breathing masks when not in use and to post "Oxygen in Use" signs for residents receiving oxygen therapy. The facility was unable to provide a policy regarding the storage of breathing masks prior to the survey exit.