Failure to Change Oxygen Tubing Weekly as Required
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed every seven days for one resident, as required by facility policy. During observations, a resident was noted to have oxygen tubing in use that was labeled with a date indicating it had not been changed for over two weeks. The Infection Control Preventionist, who is also a Registered Nurse, stated that she did not monitor or track the use of oxygen tubing through the infection control program and did not perform audits to ensure compliance with the seven-day change policy. The Director of Nursing confirmed that the expectation was for the Infection Control Preventionist to conduct monthly audits and random checks to verify that oxygen tubing was being changed and dated as per policy. Review of the facility's policy confirmed that oxygen tubing should be changed weekly and as needed if soiled or contaminated.
Plan Of Correction
F880 – Infection Prevention & Control Element #1: R#61 was assessed by the Director of Nursing or designee to ensure no lasting effects related to outdated oxygen tubing. Element #2: A facility-wide audit will be completed by the Director of Nursing and/or designee to ensure compliance with changes to oxygen tubing. Element #3: The Administrator reviewed the policy on Oxygen Administration and revised as necessary. Clinical staff were provided re-education related to infection control and oxygen administration. Element #4: The Infection Preventionist and/or designee will conduct rounds 3 times per week for 12 weeks to monitor infection control practices and ensure oxygen tubing is changed per policy. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025