Failure to Maintain and Label Oxygen Therapy Equipment per Policy
Penalty
Summary
Surveyors identified that the facility failed to ensure oxygen therapy was administered and maintained according to physician orders and facility policy for two residents. The facility's policy required licensed clinicians to administer oxygen as ordered, change humidifier bottles when empty, and date equipment. For one resident with chronic obstructive pulmonary disease (COPD), observations revealed the oxygen humidification bottle was stored directly on the floor, was empty, and neither the bottle nor the tubing was dated. These issues persisted over two consecutive days, and a registered nurse confirmed the deficiencies during an interview. For another resident, also with COPD, staff were ordered to administer oxygen with humidification as needed, clean the concentrator, and change tubing weekly. Observations showed the nasal cannula and tubing were left across the bed with the cannula on the floor, and the humidification bottle was also on the floor with broken attachment straps, preventing it from being secured to the concentrator. The bottle was not dated, and these conditions were confirmed by a staff member during an interview. The Nursing Home Administrator acknowledged that humidification bottles should not be stored on the ground and should be dated when changed. The findings were based on clinical record reviews, facility policy, direct observations, and staff interviews, and demonstrated a failure to follow established protocols for oxygen therapy equipment maintenance and infection control.
Plan Of Correction
Resident #3 concentrator fixed, and humidifier bottle and tubing replaced. Resident #62 concentrator fixed, oxygen bag replaced and dated per policy, humidifier bottle and oxygen tubing replaced. To identify like residents that have the potential to be affected, DON/designee audited residents receiving oxygen therapy to ensure concentrator working properly, humidification bottle not on floor, and documentation present in the electronic clinical record. To prevent this from recurring, licensed staff will be educated on the oxygen administration policy by the DON/designee. To monitor and maintain ongoing compliance, DON/designee will audit 5 residents weekly x4 then monthly x2 to ensure concentrator working properly, humidification bottle changed, tubing changed, and documented in the electronic record. Result to QAPI for recommendation and follow-up.