Failure to Prevent Oxygen Tubing Contamination
Penalty
Summary
Facility staff failed to implement proper infection control practices for a resident who was receiving continuous oxygen therapy. Multiple observations showed that the resident's oxygen tubing was repeatedly allowed to drag on the floor, become tangled around the wheelchair axle, and rest under the wheelchair in various locations throughout the facility, including the dining room and the resident's room. These observations occurred over two consecutive days and were witnessed by surveyors at different times. Interviews with facility staff, including a licensed nurse, administrative staff, and a CNA, confirmed that the oxygen tubing should not have been dragging on the floor and should have been secured in a designated pouch or pocket on the wheelchair. The facility's policy on oxygen administration did not address the proper storage and management of oxygen-delivering devices to prevent contamination or infection, contributing to the deficiency.