Failure to Change and Sanitarily Store Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and COPD by not adhering to physician's orders and professional standards. Specifically, the resident's oxygen tubing was not changed weekly as ordered, and the tubing was frequently undated and not stored in a sanitary manner. Multiple observations showed the oxygen tubing resting on unsanitary surfaces such as books and a container of bird seed, and the tubing was not consistently labeled with the date of change. The resident reported that staff had not changed the tubing in several weeks, and this was not the first occurrence of such neglect. Review of the resident's records confirmed a physician's order to change the oxygen tubing weekly, label it with the date and initials, and store it in a respiratory bag when not in use. Documentation in the Treatment Administration Record indicated that the tubing was supposedly changed and labeled as ordered, but direct observations and resident interviews contradicted this. Staff interviews confirmed knowledge of the required procedures, but the Director of Nursing acknowledged ongoing issues with compliance, including a previous grievance regarding the same concern.