Failure to Change Oxygen Tubing per Policy
Penalty
Summary
The facility failed to ensure that oxygen tubing for residents requiring supplemental oxygen was changed every seven days as per facility policy. For three of seven sampled residents, clinical record reviews and direct observations revealed that the oxygen tubing was not changed within the required timeframe. One resident with acute respiratory failure, COPD, and anxiety disorder was observed using oxygen tubing labeled with a date ten days prior, despite documentation indicating it had been changed more recently. Another resident with pneumonia, heart failure, and COPD was found with oxygen tubing labeled with a date seven days past the scheduled change, and there was no active physician's order to change the tubing weekly. A third resident with acute and chronic respiratory failure, CHF, and COPD was observed with oxygen tubing that had not been changed for over two weeks, and similarly lacked an active physician's order for weekly tubing changes. Interviews with the DON and a regional nurse confirmed that the facility's policy required weekly tubing changes on the 11PM-7AM shift, and that staff were expected to document these changes accurately. However, the observations and record reviews indicated that the tubing was not changed as required, and documentation did not reflect actual practice. The facility's policy, dated 01/19/18, directed that standard nasal cannula/tubing be changed every seven days or sooner if soiled, and that change dates be documented in the medical record, but these procedures were not consistently followed for the residents reviewed.