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F0695
D

Failure to Label and Change Oxygen Tubing per Facility Policy

Big Bear Lake, California Survey Completed on 05-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident receiving oxygen therapy did not have their oxygen tubing labeled to indicate the date it was last changed, as required by facility policy. During an observation, the resident was found in bed with oxygen running at three liters per minute, and the tubing lacked any label or date. A Licensed Vocational Nurse confirmed that the tubing was supposed to be changed weekly and labeled accordingly, but this had not been done. Further review of the facility's policy and procedure for oxygen use confirmed that both the humidifier bottle and oxygen tubing should be changed every Sunday night by a licensed nurse, with a label attached noting the date, time, and nurse's initials. The Director of Nursing acknowledged that the staff did not follow this policy. The resident involved had a medical history including dementia, diabetes, and osteoarthritis, and was admitted with these diagnoses.

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