Failure to Maintain Clean Respiratory Equipment and Prevent Infection
Penalty
Summary
The facility failed to maintain cleanliness and prevent the spread of infection in the provision of respiratory care equipment for three residents. Observations revealed that the oxygen concentrator filters for all three residents were covered with a large amount of gray, fluffy substance, indicating that the filters had not been cleaned as required by facility policy. The policy specified that filters should be removed, rinsed, and dried weekly or more often if needed to keep them clean and free of dust. Additionally, for two residents, the oxygen tubing and nasal cannula were found lying on the floor, which was confirmed by both resident statements and staff interviews. The residents involved had significant medical conditions, including obstructive sleep apnea, end stage renal disease, high blood pressure, chronic obstructive pulmonary disease, respiratory failure, and obesity. Physician orders for these residents included continuous or as-needed oxygen therapy via nasal cannula. Despite these orders, the equipment used to deliver oxygen was not maintained in a sanitary manner, as evidenced by the dirty filters and tubing/cannulas in contact with the floor. The DON confirmed that the observed conditions did not meet facility standards for respiratory care equipment cleanliness.