Deficiency in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three residents diagnosed with Chronic Respiratory Failure with hypoxia. Resident 406's clinical record did not contain a physician's order for oxygen therapy, yet the resident was observed wearing oxygen. Additionally, the oxygen concentrator in Resident 406's room had a filter with an abundance of grey, fuzzy substance. Resident 18 had a physician's order for oxygen at 2 liters per minute continuously, but the oxygen concentrator filter in their room also had a buildup of whiteish, grey, fuzzy substance. Similarly, Resident 114 was observed with an oxygen concentrator filter containing a buildup of grey, fuzzy substance. During an interview, the Unit Manager acknowledged that the filters in these rooms needed cleaning, indicating a lapse in maintaining equipment hygiene.
Plan Of Correction
Resident 406 oxygen orders are completed and concentrator filter was cleaned upon discovery. Resident R18 and Resident R114 oxygen concentrator filters were cleaned upon discovery. Oxygen concentrators currently in use were checked and filters cleaned as needed. Staff development nurse/designee re-educated licensed staff on cleaning of filters per orders. Unit Manager/designee will audit random oxygen concentrators weekly to ensure that filters are clean and report findings to QAPI committee monthly.