F0880

D

Failure to Follow Oxygen and Respiratory Therapy Infection Control Practices

Glendale, California Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s implementation of its infection prevention and control program related to oxygen and respiratory therapy equipment for one resident. The resident was admitted with chronic respiratory failure, obstructive pulmonary disease, and a delusional disorder, and was cognitively intact with moderate assistance needs for ADLs. The resident had a physician’s order for continuous oxygen at 5 L/min via nasal cannula. During observation in the resident’s room, surveyors noted that the oxygen tubing in use was not labeled with a date or time to indicate when it was last changed, and the nebulizer tubing attached to the resident’s breathing treatment device was labeled with a date showing it had last been changed on 1/5/2026.

In interviews conducted at the time of observation, an LVN stated that oxygen tubing must be dated so staff know when to change it, and an RN confirmed that the oxygen tubing was not labeled and should be labeled weekly to ensure it is changed to prevent infection. The RN also stated that the nebulizer tubing, dated 1/5/2026, should have been changed every seven days and therefore should have been changed by 1/19/2026. The RN further stated there was no way to know when the oxygen tubing was last changed due to the lack of labeling or documentation. Review of the facility’s policies showed that the Oxygen Administration policy required documentation of the date and time oxygen set-up was performed in the medical record, and the Respiratory Therapy policy required changing oxygen cannula and tubing every seven days and documenting the date and time respiratory therapy was performed. These policy requirements were not followed for this resident’s oxygen and nebulizer equipment.