Failure to Change and Date Oxygen Tubing Weekly for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that oxygen tubing was changed weekly and properly dated for five residents who required oxygen therapy. Observations, interviews, and record reviews revealed that oxygen tubing and cannulas were not changed as ordered by physicians and facility policy, which required weekly changes and labeling with the date. In several cases, the tubing was not labeled at all, and in one instance, the tubing was found to be dirty and had not been changed for several weeks. Documentation on treatment administration records and flowsheets also showed missed or unsigned entries for required tubing changes. Residents affected included individuals with diagnoses such as emphysema, acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. At the time of observation, these residents were using oxygen via nasal cannula or concentrator, but their equipment was either not dated or had outdated labels. Staff interviews confirmed that all oxygen tubing should be dated and changed weekly, but this was not consistently done according to both facility policy and physician orders.