Failure to Maintain Cleanliness and Proper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper cleaning, disinfecting, and storage of oxygen care equipment for three residents who required oxygen therapy. For one resident with obstructive sleep apnea and dementia, the oxygen concentrator filter was found with a thick layer of dust, dirt, and hair, and staff were unable to clean it adequately, despite a protocol requiring weekly cleaning or replacement. Another resident with chronic obstructive pulmonary disease and congestive heart failure had an oxygen concentrator filter with visible dust and dirt, and the nasal cannula and tubing were found under the resident's back on the bed, with no plastic bag available for proper storage when not in use, contrary to facility protocol. A third resident, with a history of pulmonary embolism and respiratory failure, had oxygen tubing connected to a concentrator lying on the floor and the nasal cannula under the bed during multiple observations. There was no plastic bag provided to store the tubing when not in use, as required by the facility's standard protocol. Staff interviews confirmed that the expectation was for nurses to clean or change oxygen concentrator filters weekly and to store tubing securely in a plastic bag to prevent contamination, but these practices were not followed.