Failure to Maintain Oxygen Concentrator Filter for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident who required oxygen therapy did not have a filter in her oxygen concentrator, as observed on multiple occasions over several days. The resident, an elderly female with diagnoses including heart failure, a history of COVID, altered mental status, anxiety, and high blood pressure, had severely impaired cognition and was dependent on staff for activities of daily living. Her care plan and physician orders specified that oxygen tubing, bubble humidification, and filters were to be changed and cleaned weekly by the night shift nurse. Documentation indicated that the required maintenance was signed off as completed, but direct observation revealed the filter was missing from the concentrator. Interviews with staff, including an LVN, the DON, and the Administrator, confirmed that the filter should have been present and clean, and that its absence was contrary to facility policy and physician orders. The facility's policy required filters to be washed every seven days, and only trained licensed staff were to administer and maintain respiratory therapy equipment. The failure to ensure the filter was in place was acknowledged by staff and administration during interviews, and it was noted that the responsible night shift nurse could not be reached for clarification.