Failure to Change and Document Oxygen Tubing per Policy
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for two residents who required oxygen therapy. For one resident with intact cognition and an order for oxygen at night, the oxygen tubing was observed to be dated over two months prior, and the humidification bottle was also outdated. The resident was unsure how often the tubing was changed. Staff interviews revealed that oxygen tubing was supposed to be changed weekly on Wednesdays, as indicated in a master schedule and facility policy, but there were no sign-off sheets or documentation to confirm that this was being done. The Director of Nursing confirmed the expectation for weekly changes, and the facility policy required disposable equipment to be changed weekly and marked with the date and initials. For another resident with multiple diagnoses including heart failure and shortness of breath, the care plan identified oxygen therapy as needed, but the medication administration record did not include orders or instructions for changing the oxygen tubing. Observations on two consecutive days found the resident's oxygen tubing undated. A physician order to change and label the tubing weekly was only written after these observations. These findings demonstrate that the facility did not ensure oxygen equipment was changed and documented according to policy and professional standards for residents requiring oxygen therapy.