Failure to Consistently Change and Date Oxygen Tubing per Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care related to changing and dating oxygen tubing as ordered. One resident was observed in their room with oxygen tubing placed behind them that was not dated, despite a physician order dated 9/18/22 directing that oxygen tubing be changed out, dated, and labeled every Sunday on the night shift. Another resident was observed in the dining room with oxygen tubing dated 7/14/25, and on a later observation the same resident’s oxygen tubing was dated 7/23/25, while the July 2025 MAR documented that this resident’s oxygen tubing had been changed on 7/13 and 7/20. The ADON stated that oxygen tubing is to be changed weekly and as needed, that it should be dated when changed, and that the date on the tubing should match the date documented on the MAR, but observations and record review showed that this practice was not consistently followed for these two residents receiving oxygen therapy. These findings demonstrate that the facility did not ensure oxygen tubing was changed and dated weekly in accordance with physician orders and facility practice for two residents reviewed for respiratory care, as evidenced by undated tubing for one resident and discrepancies between tubing dates and MAR documentation for another resident.
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