Failure to Follow Respiratory Care and Infection Control Procedures
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents by not following policy procedures, physician orders, and infection control practices. Specifically, one resident with COPD was observed using oxygen at a higher flow rate than ordered, with an empty humidifier, and respiratory equipment such as a nebulizer mask and CPAP mask left uncontained and undated. The nebulizer mask was not discarded within the required seven-day period, and the humidifier had not been changed as needed. The resident confirmed the prescribed oxygen flow, but the equipment was not maintained according to policy, and staff acknowledged the lapses in equipment dating and containment. Additional deficiencies were observed for three other residents with conditions including morbid obesity, diabetes, heart failure, chronic kidney disease, COPD, and pneumonia. Their oxygen equipment, including face masks, nasal cannulas, and tubing, was found unlabeled, undated, and not properly contained when not in use. Staff interviews confirmed that oxygen equipment should be changed weekly, dated upon change, and kept in a bag when not in use to prevent cross-contamination, as per facility policy. These failures were observed during the survey and were not in compliance with the facility's own respiratory therapy and oxygen administration policies.