Failure to Maintain Emergency Respiratory Equipment at Bedside for Tracheostomy Residents
Penalty
Summary
The facility failed to maintain required emergency respiratory equipment at the bedside for two residents with tracheostomies. For one resident with diagnoses including hemiplegia, tracheostomy, chronic respiratory failure, COPD, dysphagia, and heart failure, observations on two separate occasions revealed the absence of a manual resuscitation bag at the bedside, despite care plans indicating the need to monitor for complications related to the tracheostomy. Nursing staff confirmed that such equipment should be present at the bedside for residents with tracheostomies. Similarly, another resident with chronic respiratory failure, anoxic brain injury, and a tracheostomy was found to lack a manual resuscitation bag at the bedside during multiple observations. This resident was dependent on staff for ADLs, received oxygen therapy, suctioning, and tracheostomy care, and had physician orders for daily tracheostomy care and full CPR. Both nursing and respiratory therapy staff confirmed the absence of the required emergency equipment, noting that manual resuscitation bags were only available on crash carts at the nurses' station.