Failure to Change and Label Oxygen Tubing as Required
Penalty
Summary
A deficiency occurred when the facility failed to change and label oxygen tubing for a resident with diagnoses of heart failure, hypertension, and diabetes mellitus. The resident, who was cognitively intact, was observed to have oxygen tubing without a date indicating when it was last changed. During medication administration, the resident reported to the nurse that the tubing was hard, causing a sore in his nose, and requested a new set, stating he wears it nightly and believed it had not been changed in the last thirty days. Despite this request, the tubing had not been changed or labeled as of later that day. Review of the Medication Administration Record (MAR) for the relevant months showed no documentation or instructions regarding changing the oxygen tubing. The facility's policy on oxygen therapy required weekly changes of the mask, cannula, and bottle, but this was not reflected in the MAR or Treatment Administration Record (TAR), leaving staff without guidance. The DON confirmed that the standing orders for changing oxygen tubing should have been included on the TAR to direct staff, but this was missed.