Failure to Post Oxygen Precaution Signage and Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a precautionary "No Smoking/Oxygen in Use" sign was posted on the door of a resident's room while the resident was receiving oxygen therapy. During observation, the resident was seen on 2 liters per minute of oxygen via nasal cannula, but there was no signage indicating the presence of oxygen therapy. Interviews with nursing staff confirmed the absence of the required sign and acknowledged its importance for safety, as oxygen is highly flammable and signage serves as a critical reminder to staff, residents, and visitors. Additionally, the facility did not have a physician's order for the oxygen therapy being administered to the resident. Record review and staff interviews revealed that the resident was receiving oxygen without a documented physician's order. Staff stated that a physician's order is necessary to guide proper administration, monitoring, and documentation of oxygen therapy, and that its absence means the facility could not ensure the therapy was being used effectively and safely. The resident involved had multiple diagnoses, including end stage renal disease, chronic obstructive pulmonary disease, and diabetes mellitus with a foot ulcer. The resident's cognitive function was moderately impaired, and they required substantial to maximal assistance with activities of daily living and mobility. Facility policy and procedure documents reviewed during the survey specified the need for both a physician's order and the posting of an "Oxygen in Use" sign when administering oxygen therapy, but these requirements were not met in this case.
Plan Of Correction
F695: Respiratory/ Tracheostomy Care and Suctioning CORRECTIVE ACTION Oxygen 2LPM via Nasal Canula was ordered on 3/5/25. On 3/5/25, "No Smoking/Oxygen in Use" sign was placed on resident 293's door by the IP Nurse. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/5/2025, the DON/IP nurse checked and reviewed residents with oxygen to verify that there are orders and "No Smoking/Oxygen in use" sign was placed on the door of residents' rooms. No other resident was affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, the DON/DSD in-service was provided to LN/CNA re: importance of obtaining physician order for resident receiving oxygen therapy; provide signage on residents' door indicating "No Smoking/Oxygen in use". During the daily (Monday to Friday) room rounds, the department heads will check rooms for "No smoking/Oxygen in use" signs on rooms with residents that use oxygen and report findings during the standup meeting. DON/designee will check residents that are using oxygen weekly to verify that they have orders. MONITORING COMPLIANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met. 3/28/2025 OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/5/2025, the DON/IP nurse checked and reviewed residents with oxygen to verify that there are orders and "No Smoking/Oxygen in use" sign was placed on the door of residents' rooms. No other resident was affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/25/2025, the DON/DSD in-service was provided to LN/CNA re: importance of obtaining physician order for resident receiving oxygen therapy; provide signage on residents' door indicating "No Smoking/Oxygen in use". During the daily (Monday to Friday) room rounds, the department heads will check rooms for "No smoking/Oxygen in use" signs on rooms with residents that use oxygen and report findings during the standup meeting. DON/designee will check residents that are using oxygen weekly to verify that they have orders. MONITORING COMPLIANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met. 3/28/2025