Failure to Maintain Oxygen Therapy Protocols and Equipment Cleanliness
Penalty
Summary
The facility failed to ensure that oxygen (O2) orders were in place for one resident and did not maintain O2 concentrator filters free of dust or store nasal cannulas in bags while not in use for two residents. For one resident with a history of respiratory disorders and congestive heart failure, there was no physician's order for oxygen therapy, despite the resident being observed with a nasal cannula connected to an oxygen concentrator set at two liters per minute. The concentrator's cabinet filter was visibly dusty, and the nasal cannula was left exposed to open air rather than being bagged as required by facility policy. Staff interviews confirmed the absence of an oxygen order and uncertainty regarding responsibility for cleaning the filters and proper storage of the nasal cannula. For another resident with a diagnosis of acute respiratory failure with hypoxia, the oxygen concentrator was observed to be missing a cabinet filter on multiple occasions, and the nasal cannula was also left exposed to open air when not in use. The resident did have a physician's order for oxygen therapy as needed to maintain oxygen saturation at or above 90%. Staff interviews revealed a lack of awareness about the need for filters on the concentrators and confirmed that all concentrators should have clean filters installed. These findings were based on observations, record reviews, and staff interviews.