Failure to Maintain Sanitary Oxygen Equipment for Resident
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically an oxygen concentrator and its components, was maintained in a sanitary manner for a resident receiving oxygen therapy. Observations revealed that the oxygen tubing was dated and changed, but the oxygen concentrator's filter was visibly covered with lint and dirt, which was confirmed by the surveyor upon inspection. Interviews with staff, including a hospice aide and a nurse, indicated confusion and lack of clarity regarding responsibility for the maintenance and cleaning of the oxygen equipment. The hospice aide stated she was only responsible for placing the oxygen back on the resident after care, while the nurse deferred responsibility to maintenance. The care plan for the resident did not include interventions related to the maintenance or cleaning of the oxygen equipment or its filter. The resident involved had multiple significant medical diagnoses, including atrial fibrillation, hypertensive heart disease with heart failure, type 2 diabetes mellitus, lymphedema, venous insufficiency, dementia, and acute respiratory failure with hypoxia. The resident was moderately cognitively impaired, frequently incontinent, and required extensive assistance with mobility and transfers. Despite a contract with an outside company to maintain oxygen equipment, the filter on the resident's oxygen concentrator was not cleaned or replaced as required, and there was no documentation or clear delegation of responsibility for this task in the resident's care plan or facility records.