Failure to Change and Date Oxygen Equipment per Policy
Penalty
Summary
The facility failed to ensure that oxygen equipment was changed and dated according to its own policy for a resident with orders for supplemental oxygen. Observations revealed that the oxygen tubing in the resident's room was stored in a bag dated over a month prior, and interviews with the resident confirmed that she was not receiving oxygen at any time, including at night. Despite this, the medication administration record indicated that oxygen was being administered nightly. An LPN stated that oxygen tubing was supposed to be changed weekly, but acknowledged the resident did not use oxygen often. The Director of Nursing later confirmed that the oxygen order was discontinued because the resident was not using oxygen, and the tubing and storage bag had not been changed as required, due to being overlooked. The resident in question had a medical history including Parkinson's disease, diabetes mellitus, shortness of breath, and COPD, and had a physician's order for oxygen at night for shortness of breath, with instructions to change the tubing weekly and as needed. The medical record lacked a care plan related to oxygen use, despite documentation that the resident was cognitively intact and had received oxygen during a recent assessment period. Facility policy required oxygen cannula and tubing to be changed every seven days or as needed, which was not followed in this case.