Failure to Monitor Oxygen Equipment for Resident
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of oxygen delivery equipment for a resident with chronic obstructive pulmonary disorder (COPD). Resident #16, who was severely cognitively impaired, was observed with an empty water bottle connected to her oxygen concentrator, which was still running. The oxygen tech responsible for maintaining the equipment reported that he was unable to perform the scheduled maintenance the previous week due to scheduling issues, resulting in a delay until the following Monday. Interviews with facility staff revealed inconsistencies in the understanding of responsibilities for monitoring the oxygen equipment. The Registered Nurse (RN) and Clinical Nurse Supervisor (CNS) indicated that nurses should monitor and replace empty water bottles as needed, while the Director of Nursing (DON) stated that she did not expect nurses to monitor the equipment, as an external company was responsible for it. This lack of clarity and oversight led to the deficiency in ensuring the oxygen delivery equipment was properly maintained for Resident #16.
Plan Of Correction
Element #1 Residents #16's oxygen delivery equipment water humidifier bottle has been replaced. Element #2 Residents residing in the facility requiring oxygen therapy have the potential to be affected. Their equipment has been inspected and serviced as identified. Element #3 Licensed nurses were re-educated on oxygen equipment usage and appropriate maintenance of equipment. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will conduct random weekly audits on residents who require oxygen therapy to ensure proper equipment is available and utilized. Element #5 The Administrator is responsible for sustained compliance.