Failure to Clean and Store Respiratory Equipment per Policy
Penalty
Summary
The facility failed to ensure that respiratory treatment equipment, including oxygen concentrators, nasal cannulas, and CPAP machines, was cleaned and stored according to manufacturer instructions and facility policy for multiple residents. Observations revealed that several oxygen concentrators had visible dust and debris on their filters and exteriors, with one concentrator labeled with another person's name. Nasal cannulas were found undated, improperly stored—such as hanging over wheelchair wheels or lying on the floor—and in some cases, not replaced according to the facility's weekly schedule. Documentation in the treatment administration records (TAR) was inconsistent or missing for scheduled cleaning and replacement tasks. Residents using oxygen and CPAP equipment had varying degrees of cognitive function and medical needs, including chronic respiratory failure, hypoxia, and sleep apnea. Interviews with residents indicated a lack of awareness regarding the maintenance of their respiratory equipment. For example, one resident with severe cognitive impairment could not confirm if his CPAP mask and tubing or oxygen concentrator were cleaned, while another resident with intact cognition was unaware of any replacement or cleaning of her equipment. The CPAP mask and tubing for one resident were left assembled and not cleaned or scheduled for cleaning as required. Staff interviews revealed confusion and inconsistency regarding responsibilities for cleaning and maintaining respiratory equipment. Certified medication aides and LPNs provided differing accounts of who was responsible for cleaning concentrator filters, with some believing it was a nursing duty and others attributing it to maintenance or an outside oxygen company. The infection preventionist and DON confirmed that cleaning and replacement tasks were to be documented in the TAR, but acknowledged that documentation was missing or not scheduled for some residents. Facility policies required weekly cleaning and replacement of equipment, proper storage of nasal cannulas, and documentation of these tasks, but these procedures were not consistently followed.