Failure to Label and Document Oxygen Tubing and Humidifier Changes
Penalty
Summary
Facility staff failed to follow physician orders regarding the labeling and changing of oxygen tubing and humidifier bottles for a resident receiving continuous oxygen therapy. During an observation, a resident was found using a nasal cannula connected to a humidifier bottle and oxygen concentrator, but neither the tubing nor the bottle was labeled with the date, time, or staff initials as required. The resident could not recall the exact date the equipment was last changed, and a registered nurse confirmed that the items were not labeled as per protocol. A review of the resident's medical record revealed active physician orders specifying that the oxygen tubing and humidifier bottle should be changed weekly, dated, and initialed by staff. Documentation in the Medication Administration Record and Treatment Administration Record indicated that the equipment was changed on the appropriate day, but the lack of labeling on the actual equipment did not provide verification of compliance with the orders. The Director of Nursing acknowledged the deficiency during the survey.