Failure to Post Oxygen in Use Signage for Resident Receiving Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary and safety signage outside the room of a resident who was receiving continuous supplemental oxygen therapy. The resident, admitted with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, had a physician's order for continuous oxygen via nasal cannula. Observations on two separate days confirmed that the resident was receiving oxygen through a concentrator, but there was no signage posted outside the room to indicate that oxygen was in use. Interviews with nursing staff and facility leadership revealed a lack of clarity and follow-through regarding responsibility for placing the required oxygen signage. The nurse assigned to the hallway was unaware of the location of the signage, and the DON stated that the admitting nurse or any nurse could place the signage but was unsure why it had not been done. The Administrator also acknowledged that the signage should have been in place but did not know why it was missing.