Failure to Post Oxygen Warning Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
Facility staff failed to follow appropriate respiratory care and services for a resident receiving oxygen therapy. During a tour, a resident was observed using oxygen with an oxygen humidifier bottle and tubing attached to a concentrator, but there was no oxygen usage sign posted on the resident's door or doorframe. Review of the resident's medical record confirmed physician orders for oxygen therapy and instructions to change the oxygen humidifier bottle tubing weekly. The resident's care plan also addressed oxygen therapy related to respiratory illness. Further review of the facility's oxygen administration policy revealed requirements to place an oxygen warning sign on the room door where oxygen is in use, change oxygen tubing and cannula weekly, and change the humidifier bottle every seventy-two hours or when empty. During an interview, the ADON/Infection Preventionist stated that tubing and humidifier bottles were changed weekly but was unaware of the requirement to post oxygen signage. The ADON acknowledged that the facility did not place oxygen signs on rooms where oxygen was in use, despite the policy stating this was required.