Failure to Date and Change Oxygen Tubing and Equipment as Required
Penalty
Summary
The facility failed to ensure that oxygen tubing and related respiratory care equipment were properly dated and changed according to policy for three residents who required respiratory support. Facility policy required that oxygen tubing, cannulas, masks, and small volume nebulizer (SVN) equipment be changed weekly and appropriately dated by nursing staff. However, observations revealed undated oxygen tubing and equipment in the rooms of all three residents reviewed, and in some cases, equipment was left uncovered or contained unknown liquid residue. One resident with a history of congestive heart failure, asthma, and pleural effusions was observed with uncovered SVN equipment on their bedside table, with undated tubing and a reservoir containing an unknown clear liquid. This resident had orders for SVN treatments as needed for shortness of breath and had received these treatments multiple times in the review period. Another resident with heart failure, dyspnea, and pulmonary hypertension was found with an undated oxygen mask and tubing, which the resident reported having brought from a previous hospital stay. Staff interviews revealed a lack of knowledge or adherence to the facility's policy regarding the dating and changing of oxygen equipment. A third resident with heart failure and acute respiratory failure with hypoxia was observed using an oxygen concentrator with a humidifier, but the tubing was not dated, and the resident was unsure how often the humidifier was changed. Review of this resident's records showed no specific order for changing the oxygen tubing or humidifier. Interviews with facility staff, including the Director of Nursing Services and unit managers, confirmed that the expectation was for weekly changes and dating of equipment, but this was not consistently implemented.