Failure to Post Oxygen in Use Sign for Resident on Continuous Oxygen Therapy
Penalty
Summary
The facility failed to post a No Smoking/Oxygen in Use sign outside the entrance door of a resident's room who was receiving continuous oxygen therapy, as required by the facility's policy and procedure. The resident had a history of respiratory disorders, dyspnea, and atelectasis, and was admitted with orders for continuous oxygen at 2-3 liters per minute via nasal cannula or face mask. Observations confirmed that the resident was on oxygen therapy, but there was no sign posted outside the room to indicate oxygen use. Interviews with the treatment nurse and the Director of Nursing confirmed that the facility's policy was not followed, and both acknowledged the importance of posting the sign to inform staff and visitors of the oxygen in use. The facility's policy, reviewed during the investigation, specifically required the placement of a No Smoking/Oxygen in Use sign on the outside of the room entrance door and in a designated place over the resident's bed. The absence of the required signage was directly observed and confirmed by staff.