Failure to Label and Change Oxygen Tubing per Policy
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), diastolic heart failure, and atrial fibrillation was not provided safe and appropriate respiratory care as required by physician orders and facility policy. The resident had a physician order for oxygen tubing and humidifier changes every Wednesday night shift and continuous oxygen at 2 LPM to maintain oxygen saturation above 90%. During an observation, it was found that the oxygen tubing in use for the resident was not labeled with the date it was last changed, and the Director of Staff Development was unable to confirm when the tubing had last been replaced. Further review of the facility's policy on infection prevention for respiratory therapy revealed that oxygen cannulas and tubing should be changed every seven days or as needed. The Director of Nursing acknowledged that this policy was not followed in the resident's case, as the tubing was not labeled and its change date was unknown. This failure to follow established procedures for respiratory care and infection prevention constituted the deficiency.