Failure to Change and Date Oxygen Tubing and Humidifier Bottle per Policy and Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders and facility policy for a resident requiring oxygen therapy. Specifically, the facility did not change or date the oxygen tubing and humidifier bottle as required. Facility policy stated that oxygen cannulas and prefilled humidifier bottles should be changed weekly or as needed, and physician's orders directed that oxygen tubing, supply bag, and water jug be changed weekly. Review of the resident's clinical record showed frequent use of oxygen, yet observations revealed that the nasal cannula attached to the resident's oxygen tank was not dated, and the humidifier water bottle attached to the oxygen concentrator was last dated over a month prior. Further observations on multiple occasions confirmed that the nasal cannula remained undated and the humidifier water bottle had not been changed according to the required schedule. During an interview, an LPN confirmed that both the nasal cannula and humidifier water bottle should have been changed and that the current practice did not meet the facility's policy or the physician's orders. The resident involved had a history of chronic obstructive pulmonary disease, hypertension, and heart failure, and had used oxygen therapy multiple times during the review period.
Plan Of Correction
Director of Nursing or designee will provide education to all nurses on the policy of providing oxygen and changing and dating oxygen tubing and humidifier bottles according to physician's orders by 08/30/2025. The identified resident, R84, oxygen tubing and humidifier water bottle was replaced immediately. All other residents with oxygen orders had their tubing and bottles checked to ensure we were in compliance with the required changing date. Ongoing compliance will be monitored by the Director of Nursing or designee by ensuring that all residents with oxygen orders have tubing and humidifier bottles changed weekly per policy and physician order, one time per day weekly for one month, one time per day every other week for one month and then monthly for two months. All findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.