Failure to Change and Date Oxygen Tubing Weekly for Tracheostomy Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and physician orders for weekly oxygen tubing changes for a resident receiving oxygen via tracheostomy. The resident had significant medical conditions including multiple sclerosis, chronic respiratory failure with hypoxia, tracheostomy status, encephalitis, and encephalomyelitis, and had orders for oxygen via tracheostomy collar at five liters per minute to maintain oxygen saturation above 90%. The orders and care plan specified that oxygen tubing and disposable respiratory supplies were to be changed weekly and that the oxygen concentrator and filter were to be cleaned weekly. The facility’s oxygen administration policy also required that tubing, masks, and cannulas be changed weekly and documented in the EHR. During an observation, the resident was seen in bed receiving oxygen via a tracheostomy mask, and the oxygen tubing in use was dated nearly four weeks earlier. A CNA confirmed the tubing date as 12/25/25 at the time of observation on 01/20/26, indicating that the tubing had not been changed according to the weekly schedule. This failure to change and date the oxygen tubing as required constituted non-compliance with the facility’s policy and the resident’s care plan and orders for equipment management and infection control.
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