Failure to Change and Store Oxygen Equipment per Policy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not adhering to its own policy regarding the maintenance and storage of oxygen delivery equipment. Specifically, a resident with chronic obstructive pulmonary disease (COPD), generalized muscle weakness, and neuromuscular dysfunction of the bladder was observed using a nasal cannula and humidifier that had not been changed for over a week, as indicated by the date on the equipment. Additionally, the resident's oxygen mask was found hanging from the bed and nightstand, not stored in a plastic bag as required, and at one point was almost touching the floor. The resident reported that the nasal cannula and humidifier were only changed when the humidifier bottle was empty, rather than on a weekly basis as per facility policy. Interviews with nursing staff and the Infection Preventionist Nurse confirmed that the facility's policy required weekly changes of all oxygen tubing, humidifiers, masks, and cannulas, and that unused oxygen masks should be stored in a plastic bag to prevent contamination. The staff acknowledged that the equipment had been in use longer than permitted and that proper storage procedures were not followed. Review of the facility's policy further supported these requirements, indicating that the observed practices were not in compliance.