Failure to Label Oxygen Equipment and Provide Incentive Spirometer as Ordered
Penalty
Summary
Facility staff failed to properly label oxygen tubing and humidifier bottles for a resident receiving oxygen therapy. During observation, a resident was found in bed with a nasal cannula connected to an oxygen concentrator and humidifier bottle, but neither the tubing nor the bottle was labeled with the date or time as required by physician orders. The nurse confirmed the lack of labeling and acknowledged that the expectation was to label these items when changed. Medical record review showed active orders for oxygen therapy and specific instructions to change and label the tubing and bottle weekly, with documentation indicating they had been changed, but no labeling was present during the surveyor's observation. Another resident with a physician order for incentive spirometer use was not provided with the device at their bedside, despite repeated requests to staff over several weeks. The resident reported concerns about mucus accumulation and a history of pneumonia, and stated that staff either did not know what an incentive spirometer was or told the resident it was on order. Multiple observations confirmed the absence of the incentive spirometer in the resident's room, and staff interviews revealed a lack of awareness and follow-through regarding the resident's order for the device. The deficiencies were identified through direct observation, medical record review, and staff and resident interviews. The issues included failure to follow physician orders for respiratory care equipment labeling and failure to provide prescribed respiratory therapy equipment to residents in a timely manner.