Failure to Maintain Clean Oxygen Equipment and Proper Oxygen Storage Signage
Penalty
Summary
A resident with dementia, sleep apnea, and chronic respiratory failure was dependent on staff for activities of daily living and required oxygen therapy. Physician orders specified that the oxygen concentrator filter should be rinsed or replaced weekly, specifically every Sunday on the night shift. Observations on two separate days revealed that the resident's oxygen concentrator intake filter had significant gray and white matter buildup, indicating it had not been cleaned as ordered. Review of the medication administration record showed that the responsible nurse did not confirm whether the filter was cleaned, citing being busy during the shift. The order to clean the filter was present on the medication administration record, but the task was not completed. Additionally, the facility failed to post required cautionary oxygen signage on one of two oxygen storage rooms where full portable oxygen cylinders were kept. Observations confirmed that a storage closet containing 48 full oxygen tanks lacked the necessary cautionary signage. Interviews with facility leadership confirmed that such signage was expected but not present at the time of the survey.