Failure to Ensure Safe and Appropriate Oxygen Therapy Practices
Penalty
Summary
Surveyors identified multiple deficiencies related to the provision of safe and appropriate respiratory care for residents requiring supplemental oxygen. Several residents with physician orders for oxygen therapy were observed receiving oxygen via nasal cannula, but there were no cautionary oxygen signs posted either outside or inside their rooms. Staff interviews confirmed that signage was expected but not present, and both the DON and Administrator were unaware of the missing signs despite recent audits intended to ensure compliance. In one case, a resident had two active physician orders for different oxygen flow rates (2 L/min and 3 L/min) simultaneously, and both orders were being documented as administered on the MAR. The nurse responsible for entering the new order acknowledged that the previous order should have been discontinued but was not, resulting in conflicting active orders. The Medical Director, DON, and Administrator all confirmed that the previous order should have been discontinued when the new order was received. Additionally, a resident's oxygen tank was found unsecured in the room, not placed in a holster or rack, and there was no oxygen signage present. Staff interviews revealed a lack of awareness regarding the unsecured tank and missing signage, despite expectations that all oxygen users have appropriate signs posted and equipment properly secured. These findings were based on direct observations, record reviews, and staff interviews.