Failure to Maintain Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain respiratory care equipment appropriately and in accordance with physician's orders for five residents. The facility's policies on oxygen concentrators and therapy were not followed, as evidenced by observations and staff interviews. Specifically, the oxygen concentrator filters for several residents were found to be covered with a white/grey fluffy substance, indicating they were not cleaned properly. Additionally, there was a lack of evidence in the clinical records for physician's orders regarding humidification and cleaning of the concentrator filters. Resident R4's clinical record did not show a physician's order for humidification or cleaning of the oxygen concentrator filter. Observations revealed that the external surface of the filter was initially covered with a white/grey substance, and later, the internal surface was also found to be unclean. The humidifier bottle was found empty and later placed on the floor, which was confirmed by the Director of Nursing as inappropriate. Similar issues were observed with Residents R40, R75, R95, and R205, where the internal surfaces of their oxygen concentrator filters were not clean, and it appeared that the filters had been turned around. The Director of Nursing confirmed the deficiencies during observations, and the Regional Director of Nursing acknowledged the lack of physician's orders and treatment records for cleaning the concentrator filters. The facility's failure to adhere to its policies and ensure proper maintenance of respiratory care equipment resulted in deficiencies for the residents involved, as documented in the report.
Plan Of Correction
Resident R4 now has a physician order/treatment to provide humidification to his/her supplemental oxygen. Resident R4, R40, R75, R95, and R205 oxygen concentrator filters were cleaned immediately, and orders verified that all concentrator filters are to be cleaned weekly and/or as needed. Resident R4's prefilled humidifier was immediately removed from the floor. All residents who have respiratory equipment have had their orders verified. All respiratory equipment has been checked to ensure cleanliness, which includes but is not limited to the filters. The respiratory therapists and all nursing staff will be inserviced to include but not limited to the policy and procedure for oxygen concentrators, Oxygen Therapy, Oxygen Therapy via Nasal Cannula as well as the policy and procedure for following physician orders. The Director of Nursing and/or designee will monitor physician orders for all residents on oxygen for use, flow rate, and oxygen concentrator cleanliness daily for two weeks, bi-weekly for two weeks, and weekly for four weeks, and monthly thereafter for compliance. The results will be taken to the Quality Assurance and Performance Improvement Committee for review and further recommendations.