Failure to Provide Safe and Consistent Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring such care, as evidenced by observations, interviews, and record reviews. One resident with a history of chronic obstructive pulmonary disease (COPD) and a smoking habit was found with a nasal cannula (NC) that had visible discoloration in various shades of brown, which had not been replaced despite being dirty. The resident reported that the NC tubing was never changed and the oxygen concentrator was not cleaned. Physician orders and the care plan specified that oxygen tubing and humidifier bottles should be changed weekly and as needed, but these instructions were not followed. Another resident, also diagnosed with COPD, was observed with an oxygen concentrator humidification bottle that was not dated. Although the resident stated that the nurse checked the tubing and bottle during rounds, he could not recall when the water bottle was last changed. Physician orders required the humidification bottle to be checked for adequate distilled water every shift and the tubing to be changed weekly, but the lack of dating on the bottle made it unclear whether these procedures were being followed as ordered. Interviews with nursing staff and facility leadership revealed inconsistencies in the implementation of respiratory care protocols. Staff acknowledged that tubing was supposed to be changed weekly and as needed, but there was no system in place to date the NC or humidification bottles, and responsibilities for cleaning equipment were not clearly defined. The facility's policy required weekly documentation of tubing changes, but observations and staff statements indicated that these procedures were not consistently carried out, resulting in deficiencies in respiratory care for the residents involved.