Failure to Change and Date Oxygen Supplies per Policy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for four residents who were receiving oxygen therapy. Surveyors observed that oxygen humidification bottles and tubing were not changed according to facility policy, which requires weekly changes and dating of equipment. Specifically, two residents were found with humidification bottles dated over two weeks prior to the observation, and their oxygen tubing was not dated. Another resident was using oxygen equipment that was not dated, and there was no documented physician order for oxygen or for changing the tubing and humidification bottle. A fourth resident had an order to change oxygen supplies weekly, but the humidification bottle was dated a week prior and the tubing was not dated. Interviews with facility staff confirmed that the policy is to change oxygen humidification bottles and tubing weekly, every Sunday by the night shift. However, observations and record reviews indicated that this policy was not consistently followed for the residents reviewed. The affected residents had diagnoses or orders indicating the need for oxygen therapy, including chronic obstructive pulmonary disease and orders for oxygen at specific flow rates. The lack of adherence to the facility's policy for changing and dating oxygen supplies constituted a failure to provide safe and appropriate respiratory care as required.