Failure to Provide Safe and Appropriate Respiratory Care and Oxygen Safety Measures
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for three residents requiring oxygen therapy. For two residents with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and respiratory failure, observations revealed that the oxygen concentrator filters in their rooms contained significant debris build-up, described as fluffy, crumbly, and light brown in color. Staff interviews confirmed that the filters were not being cleaned daily as required, and there was confusion among staff regarding the cleaning schedule and responsibilities. Additionally, the oxygen tubing was not consistently labeled to indicate when it was last changed, making it difficult to track compliance with weekly tubing changes. Further deficiencies were noted in the lack of appropriate oxygen in use signage on the entrances to the rooms of all three residents receiving oxygen therapy. Observations on multiple occasions confirmed that the required signage was missing, and staff interviews revealed uncertainty about who was responsible for placing the signs. The Director of Nursing stated that signage should be present on or near the resident's door whenever oxygen is in use, but this was not being consistently implemented. Additional safety concerns were observed regarding the handling and storage of oxygen tanks. In one instance, an oxygen tank was found stored upright on the floor of a resident's room without being secured in a holder, and staff were unable to identify who had placed it there. In another instance, a nurse aide was observed transporting a full oxygen tank by carrying it in her arms rather than using a cart or secure holder, contrary to facility expectations. The aide later acknowledged that a cart was available for this purpose but was unsure of its location at the time.