Failure to Maintain and Label Oxygen Equipment for Two Residents
Penalty
Summary
The facility failed to provide proper care and maintenance of oxygen equipment for two residents who required oxygen therapy. For one resident with acute and chronic respiratory failure, asthma, and COPD, observations revealed that the oxygen tubing in use was sticky and lacked a date label on multiple occasions. The facility's policy required weekly changes of oxygen tubing and labeling, but this was not followed, as the tubing remained unchanged and undated over several days. A licensed practical nurse confirmed that the tubing felt as though it had not been changed in quite some time and that night shift nurses were responsible for changing and labeling the tubing. For another resident with acute and chronic respiratory failure, observations also showed that the oxygen tubing was undated over several days, despite physician orders directing staff to change all oxygen tubing, masks, and humidification every Sunday. The lack of labeling and timely changing of oxygen equipment for both residents was directly observed and confirmed through staff interviews and record reviews, indicating a failure to adhere to facility policy and physician orders regarding respiratory care equipment.