Failure to Change and Date Oxygen Tubing for Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Specifically, the oxygen mask tubing for a resident was not changed and dated as required by facility policy and physician orders. Observation revealed that the oxygen tubing in use was dated over a month prior to the observation date, indicating it had not been replaced weekly as ordered. The resident's care plan and physician orders specified weekly tubing changes and monitoring of oxygen saturation, but these interventions were not followed. The resident involved had multiple diagnoses, including hypertensive heart disease, Alzheimer's disease with late onset, and was receiving palliative care. The resident was severely cognitively impaired and at risk for impaired gas exchange and ineffective breathing patterns. Interviews with facility staff confirmed that nurses were responsible for changing the oxygen tubing weekly, but the tubing in use had not been changed according to the schedule. There was also confusion regarding responsibility for the oxygen equipment after the resident transitioned to hospice care, which contributed to the oversight.