Failure to Change and Store Respiratory Tubing per Policy and Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that oxygen and nebulizer tubing was changed and stored according to policy and physician orders. The facility's policy required oxygen tubing to be replaced every seven days or when visibly soiled, and physician orders specified weekly changes for both oxygen and nebulizer tubing, with all tubing to be dated and stored in a bag when not in use. However, observations over several days revealed that the resident's oxygen tubing was dated more than a week prior and had not been changed as required. Additionally, the nebulizer tubing and mouthpiece were found undated and uncovered, not stored in a bag as directed by both care plan and physician order. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and both acute and chronic respiratory failure with hypoxia, and was alert, oriented, and receiving oxygen therapy. Interviews with staff confirmed inconsistent practices regarding the frequency of tubing changes and proper storage, with some staff stating changes occurred monthly rather than weekly. The Director of Nursing and Resident Care Manager both acknowledged that the tubing should have been changed, dated, and stored in a bag, but these actions were not carried out as required.