Failure to Maintain Oxygen Equipment and Provide Ordered Respiratory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory care and maintain oxygen equipment in accordance with its own policy and physician orders for three residents receiving oxygen therapy. Facility policy dated 8/15/25 required that all residents on oxygen have tubing, masks, and cannulas changed weekly and concentrator external filters cleaned weekly. For one resident with COPD, muscle wasting, and abnormal lung findings, a physician order dated 1/12/26 directed weekly cleaning of the oxygen concentrator and filter and weekly tubing changes. On observation, this resident was in the main dining room on oxygen via nasal cannula with an oxygen concentrator whose humidifier bottle was empty and still labeled with a date from earlier in the month, and the concentrator and external filter were dusty with a layer of fuzz-like debris. The respiratory therapist confirmed these observations. Another resident, admitted with constipation, hypertension, and pneumonia, had a care plan directing oxygen at 2 L with oxygen precautions and a physician order for continuous 2 L oxygen and tubing changes every seven days. During observation, this resident’s oxygen tubing was not dated, and review of the clinical record showed no evidence that the tubing was changed as ordered. A third resident with heart failure, hypertension, and depression had a physician order identical to the first resident’s, requiring weekly cleaning of the concentrator and filter and weekly tubing changes. Observation showed this resident sitting in a wheelchair connected to a concentrator by nasal cannula with undated tubing and a concentrator and external filter that were dusty with a layer of fuzz-like debris. The respiratory therapist and the DON confirmed that appropriate respiratory care and oxygen equipment maintenance were not provided for these three residents.
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