Failure to Change Oxygen Tubing per Policy
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures for one resident by not ensuring that oxygen tubing was changed every seven days as required. During a record review, it was found that a resident with severe cognitive impairment and dependence on activities of daily living was receiving oxygen via nasal cannula, and the tubing in use was dated beyond the seven-day change interval. The Director of Nursing confirmed that the tubing had not been changed according to policy and acknowledged the requirement for weekly changes. The resident's medical history included depression, hypertension, and atrial fibrillation, and a physician's order was in place for oxygen administration as needed to maintain oxygen saturation above 92%. Facility policy specified that respiratory equipment such as cannulas and humidifiers should be changed every seven days or when visibly contaminated. The failure to follow this schedule was observed during a concurrent observation and interview, and the facility's policy was confirmed through record review.