Failure to Maintain Oxygen Concentrator Filters per Physician Orders and Manufacturer Guidelines
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not maintaining oxygen concentrator filters according to physician orders and manufacturer guidelines for two residents with COPD. Both residents were receiving oxygen therapy as ordered, and their care plans included interventions for regular cleaning of the oxygen concentrator and its filters. Physician orders specified that the outside of the oxygen concentrator should be cleaned and the filter rinsed with warm water every Wednesday during the evening shift. Despite these orders, surveyor observations on multiple occasions found that the oxygen concentrator filters for both residents were coated in thick gray dust, indicating that the required cleaning had not been performed. Medication Administration Records showed that evening shift nurses had signed off on the cleaning tasks, but the physical condition of the filters contradicted these records. Interviews with nursing staff revealed a lack of awareness regarding the importance and procedure for cleaning the filters, with staff admitting uncertainty about why the task was necessary and acknowledging that the cleaning had not been completed as required. Further interviews with the unit manager and infection preventionist confirmed that the cleaning was not done as ordered and that the filters were visibly dirty. The failure to maintain the oxygen concentrator filters as per policy, physician orders, and manufacturer instructions was directly observed and acknowledged by staff, resulting in a deficiency related to the provision of respiratory care and equipment maintenance.