Failure to Provide Proper Respiratory and Tracheostomy Care
Penalty
Summary
The facility failed to provide respiratory care according to professional standards for three residents. For one resident with a tracheostomy and chronic respiratory failure, an LPN performed tracheostomy care using only saline-moistened gauze, without any cleansing agent or disinfectant, despite facility policy requiring the use of hydrogen peroxide for cleaning and disinfection. The LPN confirmed that only saline was used and acknowledged the policy requirement after reviewing it. Review of CDC recommendations also indicated that high-level disinfection is required for semi-critical patient care equipment, such as endotracheal tubes. Additionally, two other residents receiving oxygen therapy did not have their oxygen tubing changed or dated according to facility policy. One resident's oxygen tubing was not dated, and a nurse confirmed this during observation. Another resident's oxygen tubing was found to be dated more than two weeks prior, exceeding the facility's policy of weekly changes. The DON and respiratory therapist both confirmed that tubing should be changed weekly, and facility policy supported this requirement. These deficiencies were identified during complaint investigations.