Failure to Maintain Clean Oxygen Concentrator Filters for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents who required oxygen therapy. For one resident with severe cognitive impairment and diagnoses including encephalopathy and obstructive sleep apnea, the oxygen concentrator's air intake gross particle filter was repeatedly observed with a thick coating of dust on multiple occasions. Despite physician orders and documentation indicating weekly cleaning of the filter, the filter remained visibly soiled, and the resident reported ongoing difficulty breathing. Additionally, a bottle of sterile water intended for use with the concentrator was found on the floor rather than in its designated storage area. For another resident with chronic diastolic heart failure and moderate cognitive impairment, the oxygen concentrator's removable filter was also observed to be covered in a thick layer of gray dust over several days. This resident used oxygen therapy primarily at night and expressed concern about the cleanliness of the equipment, stating reluctance to breathe through a visibly dirty filter. Documentation indicated that the filter was supposed to be cleaned weekly, but observations contradicted these records, showing a lack of proper maintenance. Interviews with nursing staff confirmed that the filters should have been cleaned weekly in accordance with both manufacturer guidelines and facility policy, but acknowledged that this had not occurred. The failure to maintain clean and sanitary oxygen concentrator filters as required by physician orders, manufacturer instructions, and facility policy resulted in the equipment being left in a condition that could compromise its function and the quality of care provided to the residents.