Failure to Change and Date Oxygen Tubing for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to ensure that oxygen tubing for residents requiring respiratory care was properly labeled and changed according to facility policy. Observations and interviews revealed that six residents who were dependent on supplemental oxygen had undated oxygen tubing, and staff were unable to confirm when the tubing was last changed. The facility's policy required that oxygen tubing be changed and dated weekly, but this was not consistently implemented. Residents affected had significant medical histories, including chronic obstructive pulmonary disease, respiratory failure, dependence on supplemental oxygen, and other serious respiratory conditions. During observations, residents were found using oxygen tubing that was not dated, and both residents and staff were unable to verify when the tubing had last been replaced. Staff interviews indicated confusion regarding responsibility for changing and dating the tubing, with some staff stating it was the responsibility of nurses, while others indicated the respiratory department was responsible. Review of facility documentation confirmed the existence of a policy mandating weekly changes and dating of oxygen tubing, but this policy was not followed in practice. The deficiency was identified through direct observation, resident and staff interviews, and review of medical records and facility policies, affecting all residents reviewed for respiratory services during the survey.