Failure to Label and Change Oxygen Equipment as Required
Penalty
Summary
The facility failed to ensure that oxygen nasal cannula tubing and oxygen humidifiers were properly labeled and changed according to policy for two residents receiving oxygen therapy. For one resident with chronic obstructive pulmonary disease (COPD), observations revealed that the nasal cannula tubing in use was not labeled with a date, despite the resident actively receiving oxygen therapy. Multiple staff members, including a Licensed Vocational Nurse, the Infection Prevention Nurse, and the Respiratory Therapist, confirmed that the tubing was not dated and acknowledged that it should have been labeled and changed weekly to prevent infection, as per facility policy and the resident's care plan. Another resident, with a history of pleural effusion and Covid-19, was also found to have an unlabeled and undated nasal cannula and oxygen humidifier during observation. The Registered Nurse and Respiratory Therapist both confirmed that these items were not labeled or dated, and stated that it was standard practice to change and label them weekly. The Director of Nursing further confirmed that the lack of labeling and dating could lead to uncertainty about when to change the equipment, increasing the risk of infection. A review of facility policy indicated that oxygen cannula and tubing should be changed every seven days or as needed, and that humidifier bottles should be marked with the date and initials upon opening and discarded after 24 hours. The failure to follow these procedures was directly observed and confirmed by staff interviews and record reviews, demonstrating noncompliance with established infection prevention protocols for residents receiving respiratory care.