Failure to Post Oxygen Signage and Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic lung disease and hypertension by not posting cautionary signage outside the resident's room to indicate that supplemental oxygen was in use. During an observation, the resident was found receiving continuous oxygen via nasal cannula from an oxygen concentrator, but there was no sign outside the room to alert staff and visitors to the presence of oxygen. Staff interviews revealed that the resident had recently moved rooms and the oxygen in use sign was not transferred with him. Additionally, the facility did not have an active physician order for the resident's continuous oxygen therapy, despite the care plan specifying oxygen administration at 3 liters per minute and the resident reporting ongoing use of oxygen. The DON confirmed that the previous order for as-needed oxygen had been discontinued and acknowledged that a new order for continuous oxygen should have been entered into the facility's system, including instructions for the flowrate. The DON also stated that the facility physician needed to be notified to write an order when continuous oxygen therapy was initiated based on an outside physician's recommendation.