Failure to Administer Oxygen as Prescribed and Post Required Oxygen Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents by not administering supplemental oxygen as prescribed, not obtaining required physician orders for respiratory devices, and not posting required oxygen/no smoking signage. In one case, a resident with COPD, CHF, and chronic respiratory failure was observed receiving oxygen at a higher flow rate than ordered by the physician, and there was no signage indicating oxygen use or no smoking outside the resident's room. Nursing staff interviews revealed inconsistent monitoring of the oxygen concentrator settings and a lack of awareness regarding the absence of required signage. Another resident with acute and chronic respiratory failure, pleural effusion, COPD, and pneumonia had a prescription for a bilevel positive airway pressure machine from the hospital, but no corresponding physician order was entered into the facility's medical record. The resident's room also lacked the required oxygen in use signage. Staff confirmed that the order should have been entered upon admission and that the signage was missing. Additional residents with diagnoses including COPD, lung cancer, and acute respiratory failure were observed receiving supplemental oxygen without the required signage posted outside their rooms. Staff interviews consistently indicated that signage should be placed upon admission for any resident receiving oxygen, but this was not done for these residents. The Director of Nursing confirmed that it was the facility's expectation for both physician orders and signage to be in place for residents using oxygen or respiratory devices.