Failure to Adhere to Oxygen Orders and Equipment Cleanliness
Penalty
Summary
The facility failed to provide oxygen according to physician's orders and did not maintain cleanliness of respiratory care equipment for two residents. Resident R51, diagnosed with chronic obstructive pulmonary disease and peripheral vascular disease, had a physician's order for oxygen at 3 liters per minute (lpm) via nasal cannula. However, observations revealed that the oxygen concentrator was set at 4 lpm, contrary to the physician's order. Additionally, the filters on the oxygen concentrator were covered with a gray fluffy substance, indicating they had not been cleaned as required by the physician's order. Similarly, Resident R1, who had a tracheostomy and other complex medical conditions, had a physician's order for oxygen at 4 lpm via trach mask. Observations showed that the oxygen concentrator filter contained a gray dusty substance, suggesting it had not been cleaned according to the physician's order. A Registered Nurse confirmed the presence of the dusty substance but was unsure of the cleaning schedule. These deficiencies indicate a failure to adhere to physician's orders and maintain proper infection control practices.
Plan Of Correction
R51 as well as R1 assistive breathing device was cleaned and replaced with new equipment including a nasal cannula. Orders were reviewed and appropriate Liter per minute setting was put in place to match the physician order. Facility verified and addressed all residents were receiving oxygen per physician orders. All breathing apparatus were checked for cleanliness and cleaned per policy. Facility has educated nursing staff on the policy for cleaning breathing assisted devices and following physician orders. Director of Nursing or designee will audit 5 residents that receive oxygen therapy weekly for 6 weeks and once a month for 3 months to ensure the order matches what the resident is receiving with liters as well as cleanliness of the machines. Facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.