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F0695
D

Failure to Follow Weekly Oxygen Tubing Change Orders

Seaford, Delaware Survey Completed on 06-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident admitted with COPD and centrilobular emphysema had a physician’s order dated 7/20/24 for oxygen tubing to be changed weekly on Wednesday evenings, with each component labeled with the date and staff initials. On 6/5/25 at 10:34 AM, surveyors observed the resident’s continuous oxygen tubing labeled with a date of Saturday, May 24, 2025, and nebulizer tubing labeled with a date of Thursday, May 29, 2025. A subsequent observation at 3:15 PM on 6/5/25 showed the continuous oxygen tubing label dated Thursday, June 5, 2025. During an interview at 3:18 PM, an LPN stated she had changed the continuous oxygen tubing at the start of her 3 PM–11 PM shift on June 5, 2025, and confirmed the nebulizer tubing was still dated May 29, 2025 and should have been changed. The facility thus changed the resident’s continuous oxygen tubing after 11 days instead of weekly as ordered, and did not change the nebulizer tubing per the weekly order, failing to follow the physician’s plan of care for respiratory equipment maintenance. Findings were reviewed with the nursing home administrator, DON, and corporate representative on 6/12/25 at 12:45 PM.

See complete original report
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