Failure to Follow Oxygen Therapy Orders and Tubing Change Protocols
Penalty
Summary
The facility failed to follow physician orders for oxygen administration and did not ensure that oxygen and nebulizer tubing were changed and labeled according to facility policy for two residents. One resident with COPD and chronic respiratory failure was observed receiving oxygen at a rate higher than the physician's order, and the oxygen tubing and humidifier bottle were not labeled to indicate when they were last changed. The resident's care plan required weekly changing and labeling of the oxygen tubing, but there was no documentation in the medical or treatment records to show this was done. A registered nurse adjusted the oxygen flow to the correct rate during the observation, and the corporate nurse confirmed that both the physician's order and care plan interventions should have been followed. Another resident with acute respiratory failure and COPD was found receiving oxygen at the ordered rate, but reported that the nasal cannula had not been changed in at least two weeks and the nebulizer tubing had not been changed in over a week. Neither the nasal cannula nor the nebulizer tubing were labeled with the date of last change. Facility policy required weekly changing and labeling of oxygen tubing and changing nebulizer tubing every 72 hours or as needed, but these procedures were not followed for either resident.