Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders and facility policy for a resident requiring supplemental oxygen. Facility policy required nasal cannulas to be replaced every 7 days and oxygen tubing every 14 days, or sooner if visibly soiled or compromised. A review of the resident's clinical record showed physician's orders for continuous oxygen at bedtime and for oxygen tubing to be changed on the 2nd and 15th of each month during the night shift. Observations revealed that the resident was receiving oxygen via nasal cannula, but the tubing in use was dated from over a month prior, indicating it had not been changed as required. The resident involved had a history of atrial fibrillation, heart failure, and high blood pressure, and was admitted with orders for supplemental oxygen due to shortness of breath. During interviews, an LPN confirmed that the nasal cannula in use was dated from a previous month and acknowledged it should have been changed according to the schedule. This failure to follow physician's orders and facility policy resulted in a deficiency related to the provision of safe and appropriate respiratory care.