Unsafe Oxygen Administration Due to Obstructed Concentrator
Penalty
Summary
The facility failed to ensure safe oxygen administration practices for a resident with a history of asthma, dysphagia, dyspnea, dependence on supplemental oxygen, and obstructive sleep apnea. Physician orders required the resident to receive continuous oxygen via nasal cannula, and the care plan noted hoarding behaviors with interventions to address safety concerns. Multiple observations revealed that the resident's oxygen concentrator was surrounded by clothing, plastic cups, cardboard boxes, and trash, with items partially obstructing the air intake vent. The concentrator was sometimes not powered on, but at other times was in use with the intake vent still partially blocked. Staff interviews confirmed awareness of the resident's hoarding behaviors and the ongoing challenge of maintaining a safe environment. The LPN acknowledged the unsafe use of the concentrator, and a corporate nurse confirmed that the device's air intake should remain unobstructed during use. The manufacturer's user manual also specifies the need for unobstructed ventilation, with the device kept six to twelve inches away from other objects. Despite these requirements, the resident's room environment was not maintained in a manner that ensured safe oxygen administration.