Failure to Address Oxygen Concentrator Alarm Timely
Penalty
Summary
The facility failed to address a resident's oxygen concentrator alarm in a timely manner, affecting a resident with multiple health conditions including dependence on supplemental oxygen, pneumonia, chronic respiratory failure with hypoxia, hypertension, heart disease, COPD, hyperlipidemia, and tobacco use. The resident's care plan required continuous oxygen at three liters via nasal cannula and regular oxygen saturation checks. During an observation, the resident's oxygen concentrator was alarming due to a low flow rate set at zero, but staff passing by did not respond to the alarm. The surveyor activated the call light, but it went unanswered for several minutes, during which the resident expressed difficulty breathing and opened a window for relief. Eventually, a CNA and an RN were alerted to the situation. The RN assessed the concentrator and determined a new one was needed. However, the new concentrator also failed to work properly due to the oxygen tubing being kinked around the resident's neck. After the tubing was straightened, the resident's oxygen saturation was initially low at 81 percent but improved to 90 percent with deep breathing instructions. The deficiency was confirmed by the RNs present during the observation.
Plan Of Correction
The facility failed to ensure a resident's oxygen concentrator alarm was addressed timely for resident #45. Resident #45 was evaluated immediately, and the issue was addressed with the concentrator by switching the concentrator and fixing kinked tubing, by the Assistant Director of Nursing on 3/10/2024. To identify other potentially affected residents, an audit of all residents was conducted by the ADON with oxygen on 3/10/2025 by the Director of Nursing/designee for kinked tubing or malfunctioning concentrators. To prevent reoccurrence, education was conducted for all licensed nursing staff regarding oxygen monitoring and observation of equipment and tubing on 3/20/2025 by the Director of Nursing/designee. To evaluate preventative actions taken, audits of call for 3 residents 3 times a week for 4 weeks will be conducted by the Director of Nursing/designee. Audit findings will be reviewed with the QAPI committee weekly for recommendations.