Failure to Post Oxygen Cautionary Signage for Residents Receiving Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary and safety signage outside the rooms of residents receiving supplemental oxygen. This deficiency was identified for five residents who had physician orders for continuous or as-needed oxygen therapy due to conditions such as chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, pneumonia, heart failure, and emphysema. Observations on multiple occasions confirmed that these residents were receiving oxygen via nasal cannula connected to either oxygen concentrators or portable tanks, yet no signage was present outside their rooms to indicate oxygen was in use. Interviews with nursing staff, including nurses and the Director of Nursing (DON), revealed that staff were either unaware of any requirement or policy to post oxygen signage on individual resident room doors. The DON confirmed that the facility's practice had been to only place oxygen signage at major entry points, based on the facility's smoke-free campus policy, and that this had been the standard for several years. Staff interviews further indicated a lack of knowledge or clarity regarding the need for room-specific oxygen signage, even when new oxygen orders were initiated for residents. The deficiency was consistently observed across all five residents reviewed for respiratory care, with each resident actively receiving oxygen therapy during the surveyors' visits. Despite the presence of oxygen equipment and active therapy, there was no cautionary or safety signage posted on or near the doors of these residents' rooms. The absence of such signage was confirmed through direct observation and staff interviews, and the facility's policy was cited as the reason for this omission.