Failure to Change Oxygen Tubing Weekly as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed weekly as required by physician orders and facility policy for three residents who were reviewed for respiratory care. Observations revealed that the oxygen tubing for these residents was not changed within the required weekly interval, with tubing dated nine days prior to the observation date. Interviews with a CNA confirmed awareness that tubing should be changed weekly, and the Director of Nursing also confirmed the expectation for weekly changes and proper dating of tubing. The affected residents had significant respiratory diagnoses, including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen. Physician orders and care plans for these residents specifically required weekly changes of oxygen tubing, and the facility's policy also mandated this practice. Despite these clear directives, the tubing was not changed as scheduled, and the deficiency was identified through direct observation, record review, and staff interviews.