Unclean and improperly stored oxygen tubing was observed for two residents receiving O2. One resident’s tubing was left unbagged on top of the concentrator, while another resident’s unbagged tubing was connected to a portable tank on a wheelchair with the prongs touching the seat cushion and additional tubing tucked under the blankets. Records lacked evidence that tubing was changed weekly or that the concentrator filter was cleaned, despite facility policy requiring weekly cleaning and storage in plastic bags when not in use.
Respiratory care and the oxygen care plan were not followed for a resident with COPD. Staff observed the resident receiving O2 by NC at 1.5 LPM even though the current provider order was for 2 LPM continuously for SOB, and the resident was unsure of the correct setting. The care plan still listed oxygen as PRN at 1-2 L to keep O2 sat at or above 90%, and the RN and Regional Director confirmed the plan had not been updated to match the current order.
Failure to provide ordered respiratory care for two residents. One resident was observed in the dining room wearing nasal cannula tubing connected to an empty O2 tank, and an RN confirmed the tank was empty even though the resident was ordered continuous O2. Another resident had orders for continuous O2 up to 5 LPM and PRN albuterol for dyspnea, but the record showed O2 was given at 8 LPM without evidence of new orders, PRN neb treatments, or provider notification.
Improper Storage of Respiratory Equipment: The facility failed to maintain sanitary respiratory care equipment for 3 residents. A resident’s oxygen tubing was found on the floor, and two other residents had nebulizer tubing and masks left unbagged and exposed on a bedside table and shelf. The DON confirmed two of the findings, and an LPN confirmed the third. Facility policy required unused nasal cannulas to be bagged and nebulizer parts to be rinsed, air dried, and stored in a respiratory set up bag.
Respiratory equipment was not handled or documented according to orders. A resident on continuous O2 had unbagged, undated NC tubing stored with the prongs touching a wheelchair, floor, and concentrator, and staff placed the cannula back in use after it had contacted the floor while the O2 flow was set outside the ordered range. Another resident’s nebulizer tubing and mouthpiece were stored on the bed and lacked evidence of daily disinfection and proper storage. A third resident’s O2 equipment remained in place after O2 was discontinued, and another resident wore O2 without a current provider order or documentation of O2 amount and sat monitoring.
Failure to maintain sanitary respiratory equipment for two residents receiving O2 therapy. One resident had multiple nasal cannulas in the room, including unlabeled tubing on a wheelchair and oxygen cylinder caddy, and the resident stated the tubing on the face had not been changed as labeled. Another resident was observed with O2 tubing dated weeks earlier, while the charge nurse said tubing was believed to be changed weekly. Records showed weekly tubing changes were ordered, but documentation was incomplete and did not match the observations or the facility policy.
Unsanitary oxygen equipment and tubing storage: Two residents receiving O2 via nasal cannula were observed with dirty concentrators, including dust, dirt, and debris buildup on the machines and filter. One resident’s record had an order for weekly tubing changes but no evidence the filter was cleaned regularly. The DON stated there was no process for storing nasal cannulas or tubing when not in use, and tubing was being rolled up or hung on the concentrator without a bag.
Surveyors found that emergency respiratory equipment, including an Ambu bag, resuscitation mask, and oxygen tubing, was stored in poor condition, with items being dirty, discolored, expired, or overdue for inspection. The DON confirmed that night shift staff were responsible for maintaining the emergency cart and acknowledged the deficiencies.
A resident ordered to receive continuous O2 at 2 L/min via NC was observed in the dining room after breakfast with the oxygen tubing coiled on the table and not connected to an oxygen source. The resident stated that oxygen was supposed to be worn all the time, and the surveyor confirmed the issue with an RN, who then went to find portable oxygen.
Respiratory equipment was not maintained in a sanitary condition for 3 residents reviewed. One resident had oxygen tubing dated earlier than expected with no clear order or weekly change documentation, another had oxygen tubing with a date that did not match TAR entries showing weekly replacement, and a third resident’s CPAP machine, tubing, and mask were observed unbagged on a bedside table. The DON and an LPN confirmed the findings.
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