Failure to Change and Document Oxygen Tubing and Humidifier for Resident on CPAP
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required a CPAP machine with supplemental oxygen at night. The resident, who had diagnoses including hypertension, heart failure, coronary artery disease, and chronic kidney disease, was observed with undated oxygen tubing and a water humidifier that was not dated and contained very little water. On subsequent observation, the water humidifier was found to be empty. The resident was unable to recall when the tubing or humidifier had last been changed. Review of the Treatment Administration Records (TAR) from December 2024 to July 2025 showed no documentation that the oxygen tubing or water humidifier had been changed or replaced for this resident. Staff interviews revealed that the expectation was for oxygen tubing to be changed weekly, dated, and documented on the TAR, and for the water humidifier to be dated and changed as needed. However, the resident's oxygen tubing change was not listed on the TAR, and one RN was unaware that the resident was on oxygen with the CPAP machine. The Director of Nursing confirmed that the facility did not have a policy regarding oxygen administration or services, but expected staff to change and date the oxygen tubing weekly.