Failure to Date Oxygen Tubing for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to follow its policy regarding the labeling of oxygen tubing for two residents who were receiving continuous oxygen therapy. Both residents had complex medical histories, including conditions such as end stage renal disease, heart failure, diabetes, respiratory failure, and other chronic illnesses. Physician orders and care plans for both residents specified that oxygen tubing and related equipment should be changed regularly, with instructions to change and date the tubing weekly or every night shift on a specified day. However, during observations, surveyors found that the oxygen tubing in use for both residents was not labeled with the date it was last changed, as required by facility policy. Interviews with nursing staff, including LPNs and the DON, confirmed that the expectation was for oxygen tubing to be dated when changed, and that this responsibility fell to the nursing staff, particularly the night shift. Despite this, the tubing observed on both residents was not dated, and one resident was unaware of how often their tubing was changed. The facility's written policy clearly stated that all disposable respiratory equipment must be labeled with the date when placed in use, but this procedure was not followed for the two residents reviewed.