Failure to Provide Safe and Appropriate Respiratory Care and Required Oxygen Safety Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents who required continuous oxygen therapy. One resident did not receive oxygen at the rate ordered by the physician, as observations showed the oxygen was administered at 1.5 liters per minute instead of the prescribed 2 to 5 liters per minute. This discrepancy was confirmed by both a registered nurse and a review of the resident's medical orders, which specified the required oxygen flow rate to maintain adequate oxygen saturation levels. Additionally, two other residents who were on continuous oxygen therapy did not have the required 'No Smoking/Oxygen in Use' signage posted at the entrance to their rooms, as mandated by the facility's own policy and procedure for oxygen administration. Observations and interviews with nursing staff and the Director of Nursing confirmed the absence of these safety signs, despite the residents' ongoing use of oxygen. The lack of proper signage was noted during multiple observations and was acknowledged by facility staff as not being in compliance with established procedures.