Failure to Maintain and Document Proper Respiratory Equipment Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents who required such care, as evidenced by observations, interviews, and record reviews. Specifically, for five residents reviewed for respiratory care, deficiencies were noted including nebulizer masks not being bagged for four residents, and nasal cannula (NC) tubing not being dated for two residents. Additionally, care plans for these residents did not address their respiratory treatments, despite physician orders and ongoing needs for respiratory support. Staff interviews confirmed that the expected protocols for cleaning, bagging, and dating respiratory equipment were not consistently followed. Resident records revealed that these individuals had significant medical conditions such as Alzheimer's disease, vascular dementia, metabolic encephalopathy, and acute respiratory issues with hypoxia. Most were dependent on staff for personal care and required assistance or setup for meals. Despite these needs, care plans often omitted respiratory care interventions, and staff failed to ensure that equipment was properly maintained and stored according to professional standards and facility expectations. Observations included unbagged nebulizer masks left on nightstands and undated NC tubing in use, with some equipment showing visible debris. Interviews with nursing staff, the DON, and the administrator confirmed that the facility's protocol required respiratory equipment to be cleaned, bagged, and dated, and that failure to do so could result in infection. However, staff admitted to missing these steps during rounds, and the facility was unable to provide a respiratory care policy when requested. No interviews were conducted with weekend night shift nurses regarding respiratory equipment protocol.