Failure to Change and Label Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen equipment, specifically oxygen tubing, was properly changed and labeled for four residents who were receiving oxygen therapy. During observations, it was noted that multiple residents were using oxygen via nasal cannula or portable tank, but their oxygen tubing was not dated as required. Interviews with staff, including an LPN and a CNA, revealed uncertainty about who was responsible for changing and labeling the tubing. Physician orders for each resident specified that oxygen tubing should be changed monthly during the night shift and as needed, but this was not consistently followed. Further interviews with nursing staff and the Assistant Director of Nursing confirmed that nurses are responsible for dating and changing oxygen tubing, with some tubing scheduled for weekly or monthly changes depending on the order. The facility's policy also required monthly and as-needed changes for nasal cannulas. The deficiency was attributed to missed responsibilities, particularly on the third floor after the departure of the former Director of Nursing, and a lack of clear communication regarding staff duties for changing and labeling oxygen tubing.