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.
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 with orders for supplemental oxygen and CPAP/BIPAP treatments experienced multiple episodes of low oxygen saturation, but there was no documentation that the provider was notified as required. Additionally, provider orders lacked clarity regarding when and how CPAP/BIPAP and supplemental oxygen should be used, and the DON confirmed these gaps in documentation and order clarity.
Surveyors found that an oxygen concentrator and tubing were left at the bedside of a resident who no longer required oxygen, and that two residents receiving oxygen therapy had their tubing improperly stored, with a nasal cannula found on the floor. Staff confirmed that tubing should be stored in a sanitary manner, but this was not done, resulting in unsanitary conditions.
Surveyors found that several residents with respiratory conditions were using oxygen tubing and nebulizer equipment that was not changed or stored according to physician orders and facility policy. Staff documented tubing changes as completed, but observations showed outdated tubing in use and improper storage of respiratory equipment, indicating a failure to maintain a sanitary environment and follow prescribed care schedules.
Surveyors found that two residents did not receive proper infection control for their respiratory care equipment. A nebulizer mask and tubing were left unbagged on a bedside table, and a CPAP machine lacked documentation of cleaning or maintenance.
A resident receiving daily oxygen therapy had a provider order requiring regular assessment of respiratory rate, skin color, and breath sounds every shift. Review of clinical records showed no documentation that these assessments were completed as ordered, a fact confirmed by the DON, Administrator, and Clinical Market Advisor.
A resident with physician orders for nightly CPAP therapy was unable to use their machine due to missing tubing, and the facility did not obtain the required part for an extended period. Documentation and staff interviews confirmed that the resident was not provided with the ordered respiratory care, resulting in multiple hospitalizations related to hypoxia before the missing equipment was finally acquired.
A resident receiving oxygen therapy was observed using an oxygen concentrator with a very dusty filter on two separate days. Despite manufacturer instructions and facility policy requiring regular cleaning of the filter, staff did not ensure the filter was maintained in a sanitary condition, as confirmed by surveyor observation and the DON.
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