Failure to Maintain Adequate Oxygen Supply and Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide adequate respiratory care by not maintaining a sufficient number of portable oxygen tanks for residents with physician orders for continuous supplemental oxygen therapy. On the date of the survey, there were 55 residents with active orders for continuous supplemental oxygen, but only 46 portable oxygen tanks (43 E tanks and three H tanks) were available on site. This shortfall was confirmed by the respiratory therapist, who acknowledged that in the event of an emergency requiring evacuation, there would not be enough portable oxygen tanks to meet the needs of all residents requiring continuous oxygen. Additionally, the facility did not ensure that respiratory equipment was maintained in a clean and sanitary condition for a resident using a BiPAP machine. The BiPAP machine basket and stand were observed to be overflowing with trash, used facial tissues, empty soda cans, and an unlabeled urinal. The resident reported that he had requested staff to clean the BiPAP machine, but it had not been done. There was no documentation in the medical record, medication administration record (MAR), or treatment administration record (TAR) indicating that the BiPAP machine had been cleaned as required by facility policy. Interviews with nursing staff confirmed that the BiPAP machine should have been kept clean for infection prevention and that the urinal should have been labeled and not stored on the BiPAP stand. The Director of Nursing verified the findings, and staff could not provide evidence that the required cleaning had occurred, despite facility policy outlining specific cleaning procedures for such equipment.