Failure to Provide Safe Tracheostomy and Respiratory Equipment Care
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory and tracheostomy care in accordance with its own policies and professional standards for multiple residents. One resident with COPD, anxiety, hip fracture, and a tracheostomy was receiving tracheostomy care, but the clinical record and care plan did not include the type and size of the tracheostomy tube as required. Observation showed a suction canister at the bedside dated over a month prior, half full of white/light yellow substance, and an RN confirmed there was no order or care plan specifying the trach tube type/size and that the suction canister had not been changed since the earlier date. Another resident with anemia, hypertension, and depression had physician orders to change oxygen tubing weekly, label it with the date, and apply and date a humidifying water bottle weekly. Observation found this resident sleeping in bed with oxygen equipment in use, but the oxygen bottle and tubing were not dated as ordered, which the RN verified. A third resident with diabetes, obstructive sleep apnea, and renal insufficiency had an order for CPAP with oxygen bleed and a care plan for oxygen at 4 L/min to the CPAP device; however, the CPAP mask was observed hanging off the bedside stand and not stored in a bag when not in use, contrary to facility policy. The RN confirmed the mask was not stored appropriately. A fourth resident with atrial fibrillation, heart failure, and hypertension had an order for CPAP with oxygen bleed at night and a care plan for compliance with CPAP use. Observation showed the CPAP mask on the bedside stand and not stored in a bag when not in use, again inconsistent with policy. A fifth resident with diabetes, obstructive sleep apnea, and COPD had an order for BiPAP at bedtime and a care plan including BiPAP settings and assistance with BiPAP. The treatment record showed BiPAP use earlier in the month, but during interview the BiPAP mask was found on the floor next to the bed. This resident reported trying to use the BiPAP but being unable to apply the mask independently, stated that staff did not come in often to assist with the mask, and reported discomfort with the current mask and not being offered alternative mask options. The DON confirmed the facility failed to provide tracheostomy care consistent with professional standards and failed to provide appropriate respiratory care and equipment maintenance for all five identified residents.
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