Failure to Properly Label and Store Oxygen Equipment and Post Required Signage
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes, a history of pneumonia, and bipolar disorder, was observed to have an oxygen concentrator in their room with tubing and a nasal cannula that were undated and stored improperly, draped over the concentrator and touching the floor. The resident had an active physician order for oxygen administration as needed for shortness of breath, and had recently experienced an episode of low oxygen saturation requiring oxygen use and hospitalization for pneumonia before returning to the facility. On two separate occasions, surveyors observed that there was no 'oxygen in use' sign on the door to the resident's room, despite the presence of the oxygen concentrator and an active order for oxygen therapy. The Director of Nursing confirmed that facility policy requires an 'oxygen in use' sign to be posted whenever oxygen is present in the room, and that oxygen tubing should be labeled with the date of the last change and replaced weekly. The facility's policy also specifies these requirements, but they were not followed in this instance.