Failure to Change and Label Oxygen Tubing per Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents who required oxygen therapy. For each resident, observations revealed that the oxygen concentrator tubing either lacked a label indicating when it was last changed or was not changed as ordered. In one instance, a resident was found using an oxygen concentrator with another resident's name on the attached bag, and there was no documentation of when the tubing was last replaced. The Director of Nursing (DON) confirmed these findings and stated that her expectation was for each resident to have a dedicated oxygen concentrator and for tubing to be changed and labeled as ordered. Medical records for the affected residents showed diagnoses including chronic obstructive pulmonary disease (COPD), quadriplegia, type 2 diabetes mellitus, morbid obesity, acute and chronic respiratory failure, essential hypertension, obstructive sleep apnea, and chronic congestive heart failure. Despite having medical orders specifying the frequency for changing oxygen concentrator tubing and labeling it with the date, staff did not consistently follow these orders, as evidenced by the lack of labeling and uncertainty regarding equipment assignment.