Failure to Prevent Use of Electronic Cigarette While on Oxygen
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure, hypoxia, epilepsy, and schizoaffective disorder was observed using an electronic cigarette while receiving oxygen therapy. The resident was cognitively intact but dependent on assistance for mobility. Multiple observations and interviews confirmed that the resident regularly used an electronic cigarette while on oxygen, and staff provided inconsistent guidance regarding whether this was permitted. The resident reported being unable to turn off the oxygen herself due to its placement out of reach and stated that she had been using the electronic cigarette with oxygen for over two years without staff intervention until the survey. The facility's policy explicitly restricted the use of electronic cigarettes while oxygen was in use, requiring oxygen to be shut off and removed prior to use. The DON acknowledged awareness of the resident's actions and confirmed that the resident did not have an order to self-administer oxygen nor had she been educated to manage it. The care plan indicated that the electronic cigarette policy would be reviewed with the resident, but there was no evidence that effective supervision or policy enforcement occurred to prevent the resident from using the electronic cigarette while on oxygen.