Failure to Maintain Clean and Properly Assembled Oxygen Concentrators
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three of six sampled residents who were receiving oxygen therapy. One resident's oxygen concentrator was found to be operating without a filter installed, as observed during a room inspection. The Infection Preventionist (IP) and Director of Nursing (DON) both confirmed that the concentrator should not be used without a filter, and that it is the responsibility of licensed nurses to ensure the cleanliness and proper assembly of such equipment. Facility policy and the manufacturer's manual both require that the filter be present and cleaned regularly. Additionally, two other residents were observed using oxygen concentrators with filters that were covered in dust and lint. The IP stated that the filters should be cleaned at least once a week and as needed, and that using dirty equipment is not acceptable. The DON also confirmed that the expectation is for licensed nurses to clean the concentrators twice a week and as needed, in accordance with facility policy and job descriptions that require maintaining a clean and sanitary environment. Record reviews for all three residents showed that they had medical conditions such as COPD, congestive heart failure, and generalized muscle weakness, and were receiving oxygen therapy as ordered by their physicians. The observations and interviews revealed that the required maintenance and cleaning of oxygen concentrators were not being performed as per facility policy, job descriptions, and manufacturer instructions, resulting in the identified deficiencies.