Failure to Maintain and Date Oxygen Equipment for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents receiving oxygen therapy were provided with adequate respiratory care, specifically regarding the maintenance and infection control of oxygen tubing and humidifier bottles. Observations revealed that for three residents, oxygen tubing and prefilled humidifier water bottles were not dated as required, and in one case, the oxygen tubing was found on the floor. Additionally, one resident's oxygen tubing was not stored in a plastic bag or drawer as per facility policy. These lapses were identified through direct observation, interviews with staff, and review of resident records. The residents involved had significant medical histories, including chronic respiratory conditions such as COPD, asthma, and chronic respiratory failure, as well as other comorbidities like renal insufficiency, diabetes, and anemia. Their care plans and physician orders specified the use of oxygen therapy and outlined the need for regular changing and dating of oxygen equipment. Despite these documented requirements, the facility did not consistently follow through with the necessary infection control practices, as evidenced by undated equipment and improper storage. Interviews with nursing staff and the DON confirmed that the expectation was for oxygen tubing and humidifier bottles to be changed weekly, dated, and stored appropriately to prevent contamination. Staff acknowledged the importance of these practices and stated they had received in-service training on infection control and oxygen equipment care. However, the observed deficiencies indicated a failure to adhere to both facility policy and physician orders, potentially compromising infection control for residents receiving oxygen therapy.