Failure to Maintain and Label Oxygen Equipment per Standards
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three out of four residents reviewed. Specifically, surveyors observed that oxygen supplies were not dated, humidification bottles were empty or not dated, and oxygen concentrator filters were covered with a thick layer of white buildup. For one resident with chronic obstructive pulmonary disease, the nasal cannula was not dated and the concentrator filter was dirty. Another resident, with diagnoses including chronic obstructive pulmonary disease and dependence on supplemental oxygen, was found with an empty humidification bottle and a concentrator filter coated in buildup. A third resident, admitted with acute respiratory failure and hypoxia, had both an undated humidification bottle and nasal cannula. Interviews with the Assistant Directors of Nursing confirmed these deficiencies, acknowledging that the oxygen equipment was not properly maintained or labeled according to facility policy. The facility's own oxygen administration policy requires humidifiers and tubing to be labeled with the date and time opened, and for equipment to be checked and cleaned at regular intervals. These requirements were not met for the residents observed, as documented by the surveyors.