Failure to Change Oxygen and Nebulizer Tubing per Physician Orders
Penalty
Summary
Facility staff failed to provide respiratory care services in accordance with professional standards and physician orders for two residents who required oxygen and nebulizer therapy. Specifically, staff did not change the oxygen and nebulizer tubing weekly as ordered by the physicians and outlined in the facility's policy. Observations revealed that the tubing for both oxygen and nebulizer equipment was dated well beyond the required weekly change interval for both residents. One resident, with a history of cerebral infarction, chronic heart failure, and atrial fibrillation, was dependent on staff for daily care and used continuous oxygen therapy and daily nebulizer treatments. Despite physician orders and care plan interventions specifying weekly changes and dating of tubing, the oxygen and nebulizer tubing in use was observed to be dated nearly two weeks prior, indicating it had not been changed as required. Interviews with nursing staff and the DON confirmed that the expectation was for weekly changes, and that staff administering treatments should have noticed the outdated tubing. A second resident, diagnosed with acute and chronic respiratory failure and COPD, also required oxygen therapy. Observations showed that this resident's oxygen tubing was similarly dated beyond the weekly interval specified in the physician's orders and care plan. Staff interviews confirmed that the tubing should have been changed weekly and that the observed dates did not meet this requirement.