Failure to Provide and Maintain Safe Respiratory Care Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required interventions such as tracheostomy care, tracheal suctioning, oxygen therapy, and CPAP use. Observations revealed that respiratory equipment, including nasal cannulas and CPAP masks, were not bagged or dated when not in use, and oxygen tubing and humidifier bottles were not changed or dated weekly as required by facility policy and physician orders. In one case, a resident's CPAP mask and nasal cannula were found unbagged and undated, and the resident reported that her CPAP machine and incentive spirometer had not been cleaned since admission. Another resident's oxygen concentrator was observed with visible debris, and his CPAP mask was also left unbagged and undated. Interviews with nursing staff, the ADON, and the DON confirmed that the expectation was for respiratory equipment to be changed, cleaned, and dated weekly, and for items not in use to be bagged to prevent infection. However, staff admitted to not noticing or addressing the lack of bagging and dating, and there was inconsistency in following the established protocols. The facility was unable to provide a policy specifically addressing respiratory care, CPAP storage, and tubing care and labeling, only producing a policy related to fire safety and oxygen cylinder storage. Both residents involved had significant respiratory diagnoses, including chronic heart failure, acute respiratory failure with hypoxia, and obstructive sleep apnea, and were dependent on staff for assistance with activities of daily living and respiratory equipment management. The failure to adhere to professional standards of practice and facility protocols for respiratory care and infection prevention was directly observed and confirmed through staff interviews and record review.