Failure to Maintain Clean Oxygen Concentrator Filters for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Specifically, the external filters of the resident's oxygen concentrator were observed to have a significant buildup of white dust over a three-day period. Despite an active physician order to clean the oxygen concentrator filter weekly on Sundays, and a facility policy to follow manufacturer recommendations for cleaning, the filter remained uncleaned. The resident reported that while staff changed the oxygen tubing weekly, she had never seen anyone clean the concentrator filter. Multiple observations confirmed the persistent dust buildup, and both nursing staff and the DON acknowledged the filter was dusty and needed cleaning. The resident involved had a history of hemiplegia following a stroke, type 2 diabetes, heart failure, and GERD, and was receiving oxygen via nasal cannula at 2 L/min during at least one observation. Interviews with staff revealed that the responsibility for cleaning the filters was assigned to weekend nursing staff, but the task was not completed as required. The DON noted difficulty in removing the filter and decided to provide the resident with another concentrator. The administrator confirmed that nursing staff were responsible for cleaning the filters when changing the tubing weekly, but this was not done, resulting in the deficiency.