F0695

D

Failure to Change and Date Oxygen Tubing and Humidifier Weekly

Kewanee, Illinois Survey Completed on 01-06-2026

Penalty

18 days payment denial

Summary

The facility failed to follow its own policy for changing oxygen and respiratory equipment for a resident receiving oxygen therapy. The facility’s policy dated 12/2025 required nasal cannulas and oxygen humidifiers to be changed weekly or as needed and to be dated when changed, in order to ensure safety and minimize infection transmission. A physician order dated 1/5/26 directed that the resident receive oxygen at 2–4 L via nasal cannula as needed, with oxygen tubing to be changed weekly and as needed. On 1/5/26 at 11:05 AM, the resident was observed in bed with oxygen running at 2.5 L with humidity; the nasal cannula tubing in use was dated 12/28 and the humidifier bottle in use had no date. On 1/6/26 at 11:25 AM, the same resident was again observed receiving humidified oxygen via nasal cannula, with the tubing still dated 12/28 and the humidifier bottle still lacking a date. The Interim DON confirmed that residents on oxygen should have their tubing and humidity changed weekly and stated they are usually changed on Sunday nights, but could not explain why this resident’s equipment had been missed.

These observations, combined with the documented policy and physician orders, show that the facility did not ensure weekly changing and proper dating of oxygen tubing and the humidification bottle for this resident receiving oxygen therapy.