F0695

D

Failure to Change and Date Oxygen Equipment per Physician Order and Policy

Henryetta, Oklahoma Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The facility failed to provide safe and appropriate respiratory care by not dating and changing oxygen equipment as ordered for one resident using humidified oxygen. On multiple observations over several days, the resident was seen in bed with humidified oxygen delivered via nasal cannula, with the nasal cannula and oxygen tubing not dated. The humidifier bottle and a storage bag taped or hanging from the oxygen machine were consistently dated 11/26/25, indicating they had not been changed since that date. The facility’s undated oxygen policy stated that oxygen tubing was to be changed at least monthly for infection control, and a physician’s order dated 10/16/23 directed that the resident’s oxygen tubing and humidifier be replaced monthly related to a diagnosis of acute respiratory failure.

The resident’s annual assessment dated 10/15/25 documented a BIMS score of 9, indicating moderate impairment in daily decision-making, and listed diagnoses including dependence on supplemental oxygen, acute upper respiratory infection, major depressive disorder, anxiety disorder, and need for assistance with personal care. The assessment did not show that the resident was receiving oxygen therapy, while a care plan dated 01/13/26 documented continuous oxygen administration at 2–3 L/min by nasal cannula and concentrator. During interviews, an LPN confirmed the resident was receiving 4 L of oxygen via nasal cannula, acknowledged the tubing was not dated, and believed the order was to change all equipment weekly, while stating the MAR/TAR would indicate when changes were due. The DON later stated the oxygen tubing should have been dated and that the humidifier bottle and storage bag should have been changed monthly per physician orders but were not.