Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four out of seven residents reviewed for respiratory care. Specifically, three residents who required oxygen therapy via nasal cannula were observed to have their nasal cannulas left unbagged and on the floor when not in use, contrary to professional standards and facility policy. Another resident with a tracheostomy was observed to have her trach hose on the floor rather than properly stored. These actions were inconsistent with the residents' comprehensive care plans and physician orders, which specified the need for proper respiratory equipment management. Interviews with facility staff, including an LVN, the DON, and the ADON, confirmed that the expectation was for all respiratory equipment, such as nasal cannulas and trach hoses, to be bagged or properly stored when not in use to prevent contamination. The staff acknowledged that the observed practices did not meet these expectations. Record reviews indicated that the affected residents had significant medical histories, including heart disease, heart failure, tracheostomy, and a history of COVID-19, and required varying levels of assistance with activities of daily living.