Failure to Change, Label, and Date Respiratory Supplies and Ensure Correct Oxygen Flow Rates
Penalty
Summary
The facility failed to properly change, label, and date oxygen and nebulizer supplies for four residents who required respiratory care. Observations revealed that oxygen tubing bags, humidifier bottles, and nebulizer masks were either not changed according to facility policy, not labeled, or not dated as required. For example, one resident's oxygen tubing bag was dated nearly three months prior to the observation, and another resident's oxygen tubing had a date that was altered. Additionally, some residents' respiratory equipment lacked any labeling or dating, and staff interviews confirmed that the required weekly changes and documentation were not consistently performed. Furthermore, the facility did not ensure that residents received the correct oxygen flow rates as ordered by their physicians. In one instance, a resident was observed receiving a higher flow rate of oxygen than prescribed, and staff were unsure of the correct flow rate for that resident. The facility's policy required weekly changes and proper labeling of all respiratory equipment to minimize infection risk and ensure resident safety, but these procedures were not followed for the residents reviewed.