Failure to Label Oxygen Tubing for Infection Control
Penalty
Summary
A deficiency occurred when staff failed to label the nasal cannula tubing used for oxygen therapy for a resident with chronic respiratory failure, tracheostomy, and other significant medical conditions. The resident was dependent on staff for all activities of daily living and was receiving oxygen at 2 liters per minute via nasal cannula, as ordered by the physician. During an observation, it was noted that the nasal cannula was not labeled with the date it was changed or the initials of the staff member who changed it, contrary to the facility's policy and procedure. Interviews with the infection prevention nurse and the Director of Nursing confirmed that the facility's policy requires oxygen equipment to be labeled with the date, time, and staff initials when changed, to support infection control practices. Review of the resident's records and direct observation confirmed that this labeling was not done, resulting in a failure to follow established infection control protocols for respiratory care equipment.