Failure to Timely Change Oxygen Equipment for Resident on Continuous Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident requiring continuous oxygen therapy did not have their oxygen humidification bottle and nasal cannula tubing changed in a timely manner, as required by physician orders and facility policy. The resident, who had a history of stroke, hypertension, pneumonia, and diabetes mellitus, was observed with oxygen equipment that had not been changed or dated according to the weekly schedule. The humidification canister and nasal cannula tubing were last dated over two weeks prior to the observation, and the humidification bottle contained less than a quarter of water. The resident was unable to confirm how often the equipment was changed. Interviews with nursing staff and facility leadership confirmed that the expectation was for oxygen equipment to be changed and dated weekly, specifically on Sunday nights, and that this task was the responsibility of the nursing staff. The facility's policy and physician orders both required weekly changes of the oxygen equipment. Staff acknowledged that failure to change and date the equipment as scheduled could result in lapses in infection control. The deficiency was identified through observation, interviews, and record review.