Failure to Maintain Safe and Functional Oxygen Concentrators
Penalty
Summary
The facility failed to ensure that oxygen concentrators were maintained in safe and functional condition for multiple oxygen-dependent residents. Observations and interviews revealed that several concentrators in use displayed yellow caution lights or were labeled as failed, indicating potential issues with oxygen purity or equipment malfunction. Family members reported malfunctioning units to staff, but some units continued to be used despite visible warnings. The Central Supply Coordinator and Nursing Home Administrator were unable to clearly explain the meaning of the yellow indicator lights or confirm which units had been replaced following failed inspections. Documentation showed that a significant number of concentrators had failed inspection, but there was no clear tracking of which units were removed from service or replaced. During a tour, four out of fourteen concentrators in resident rooms displayed yellow caution lights, and one had a failed sticker. The outside oxygen concentrator service provider confirmed that a yellow light could indicate a failure in oxygen purity and that such units should be removed from use. The facility's own policy required all essential equipment to be maintained in safe operating condition, but failed or potentially compromised concentrators were not promptly removed from use, placing residents at risk of receiving inadequate oxygen support.