Deficient Respiratory Care Practices and Equipment Handling
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring such care, as evidenced by multiple deficiencies in the handling, cleaning, and storage of respiratory equipment. Observations revealed that several residents' BiPAP/CPAP masks were not stored according to facility protocol for sanitation. For example, one resident's mask was found on the floor, while another's was left unbagged on a nightstand. Additionally, a resident reported that their mask had not been cleaned since admission. These actions were inconsistent with both physician orders and facility policy, which require daily cleaning and proper storage of respiratory devices in clean, dated bags when not in use. Further deficiencies were noted in the management of oxygen therapy equipment. One resident was observed wearing a nasal cannula (NC) with tubing that was not dated, and an additional, used NC was found on the resident's wheelchair seat. The resident was unable to recall when the tubing was last changed. Facility policy and physician orders specified that oxygen tubing should be changed weekly and dated, and that used tubing should be discarded immediately to maintain a clean clinical environment. Interviews with staff confirmed that these procedures were not consistently followed, and that lapses in discarding old equipment and dating new tubing had occurred. Record reviews for the affected residents showed that care plans and medical orders addressed the need for respiratory support, including BiPAP/CPAP use and oxygen therapy. However, documentation was incomplete or inaccurate in some cases, with missing or improperly coded information regarding the type of respiratory support provided. Staff interviews further confirmed that there was a lack of adherence to established protocols for cleaning, storage, and documentation of respiratory equipment, which could compromise the quality of care provided to residents requiring respiratory support.