Failure to Replace Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to a resident who required continuous supplemental oxygen. According to the resident's clinical record, physician's orders specified that oxygen tubing and canister were to be changed every Tuesday night and as needed. However, observations on two consecutive days revealed that the oxygen tubing and humidification bottle tubing in use were dated significantly earlier than the required replacement schedule, indicating they had not been changed as ordered. Interviews with nursing staff and the Nursing Home Administrator confirmed that the oxygen set-up should have been replaced according to the physician's orders, but this was not done. The resident had diagnoses including heart failure and high blood pressure and required assistance with daily care tasks.