Failure to Maintain Oxygen Tubing Off the Floor for Infection Control
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the handling of oxygen tubing for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia. The resident’s History and Physical dated 12/19/2025 indicated the resident did not have the capacity to understand and make decisions, while the MDS dated 12/25/2025 documented that the resident’s cognitive skills for daily decisions were intact and that the resident required supervision from staff for hygiene, toileting, and showering. During an observation at the resident’s bedside, the resident was asleep with an oxygen concentrator set at five liters per minute via nasal cannula. The nasal cannula was not connected to the resident and was hanging on a portable emergency light on top of the resident’s rolling table, with the oxygen tubing touching the floor. In interviews, the ADON stated that oxygen tubing should not be touching the floor for infection control, and the DON stated the resident could get an infection if oxygen tubing was touching the floor. The DON also stated that the facility did not have a specific written policy stating that oxygen tubing should not touch the floor, but that the facility’s practice was to keep oxygen tubing off the floor for infection control.
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