Failure to Maintain Sanitary Oxygen Tubing per Physician Orders
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of respiratory care, specifically regarding the maintenance of sanitary oxygen tubing for three residents who required oxygen therapy. Each resident had physician orders specifying that oxygen tubing should be changed weekly, with the tubing dated and initialed at each change. However, observations revealed that the oxygen tubing for all three residents had not been changed for at least ten days, as the tubing was last dated as changed on 6/16/25, despite observations occurring on 6/24/25 and 6/26/25. The residents involved had diagnoses including chronic diastolic and systolic congestive heart failure and were documented as requiring oxygen therapy per their care plans and physician orders. Interviews with the Director of Nursing confirmed that the facility's practice was to change oxygen tubing weekly, but the facility's written policy on oxygen administration did not specify the frequency for changing tubing. The lack of adherence to physician orders and the absence of clear policy guidance contributed to the failure to maintain sanitary oxygen tubing for the affected residents.