Deficiency in Respiratory Equipment Storage and Labeling
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored and dated according to professional standards for a resident requiring respiratory care. During an initial tour, a surveyor observed that a resident was using oxygen at 4 liters per minute via a nasal cannula, which was not dated. On a subsequent observation, the nasal cannula was found placed on top of the oxygen concentrator without being stored in a plastic bag, contrary to facility policy. Interviews with the Licensed Practical Nurse and Unit Manager confirmed that the nasal cannula should be changed weekly, dated, and stored in a labeled plastic bag when not in use for infection control purposes. The resident involved had a medical history including chronic obstructive pulmonary disease, anemia, depression, and anxiety, and was cognitively intact with a BIMS score of 15 out of 15. The resident's care plan indicated a continuous oxygen requirement of 4 liters per minute via nasal cannula, but did not include interventions for labeling and proper storage of the nasal cannula. The facility's policy on oxygen administration was undated and did not address labeling or proper storage of equipment. The surveyor's findings were presented to the facility's management, who did not provide additional information or refute the findings.
Plan Of Correction
Rose Mountain Care Center Facility ID 315384 Survey Date 12/12/24 F695 SS D **Element One - Corrective Action:** Resident #36 [R] dated and placed in a labeled plastic bag. **Element Two - Identification of At-Risk Residents:** All residents that utilize oxygen are at risk. An audit was completed on all residents utilizing oxygen to ascertain proper labeling and storage when not in use on 12/12/24. **Element Three - Systemic Changes:** All clinical staff were re-educated on labeling oxygen tubing with date and placing tubing in labeled, dated, plastic bags when not in use. **Quality Assurance:** To maintain and monitor ongoing compliance, Unit Managers/designees will audit all residents utilizing oxygen weekly x4 and monthly x3 to ensure all oxygen tubing is dated and when not in use is placed in labeled, dated plastic bag. Needed corrections will be addressed as they are discovered. Findings to be reported to Quality Assurance Performance Improvement team for review and action as necessary. Date of Completion: 12/25/24