Failure to Change and Date Oxygen Tubing and Maintain Ordered Oxygen Flow Rates
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents requiring oxygen therapy. Surveyors found that oxygen tubing was not changed or dated according to physician orders and facility policy, and oxygen flow rates were not set as prescribed. For example, one resident with chronic respiratory failure and COPD had oxygen set at four liters per minute (lpm) instead of the ordered three lpm. Another resident using BiPAP therapy had oxygen tubing that had not been changed for over a week, contrary to the weekly change requirement. Additional deficiencies included undated and unchanged oxygen tubing and humidification bottles, as well as oxygen flow rates set higher than ordered. One resident's oxygen concentrator was set to 4.5 lpm instead of the prescribed four lpm, and the humidification bottle was empty and undated. Another resident with COPD had oxygen set at three lpm instead of the ordered two lpm, and the tubing was undated. In several cases, staff interviews confirmed that the tubing had not been changed as required and that oxygen flow rates did not match physician orders. The facility's policy required oxygen to be administered per physician orders and for tubing to be labeled, dated, and changed every seven days. Despite these requirements, observations and staff interviews revealed that these protocols were not consistently followed for at least five residents with significant respiratory diagnoses, including COPD, chronic respiratory failure, and congestive heart failure.