Failure to Change and Label Oxygen Tubing as Required
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not changing the oxygen tubing as required for a resident with physician orders for oxygen therapy. The resident, who had diagnoses including COPD, respiratory failure, and anxiety, required moderate assistance with activities of daily living and utilized both an oxygen concentrator and a portable tank. Observations revealed that the tubing on the resident's oxygen tank was not labeled with the date it was last changed, and the tubing on the concentrator in the resident's room was last changed over two weeks prior, as indicated by the label dated 5/5/25. Interviews with nursing staff and the DON confirmed that facility policy requires oxygen tubing and cannulas to be changed weekly and labeled with the date and staff initials. Staff were unsure of the required frequency until reviewing the policy, which directs weekly changes. The failure to change and properly label the oxygen tubing for both the concentrator and the portable tank resulted in noncompliance with the facility's infection prevention policy.