Failure to Post Oxygen in Use Signage for Residents Receiving Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary signage indicating oxygen use outside the rooms of four residents who were receiving supplemental oxygen therapy. Multiple observations over several days confirmed that oxygen concentrators were in use via nasal cannula for these residents, but no warning signs were present on their doors. This deficiency was noted for residents with significant respiratory diagnoses, including heart failure, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and acute respiratory failure with hypoxia. Staff interviews revealed a lack of clarity and consistency regarding responsibility for placing oxygen in use signs. Agency nursing staff were unaware of who was responsible for posting the signs, and some had not noticed the absence of signage. Unit Managers and nurses described a process in which the nurse on the hall was supposed to place the sign when a resident was admitted with an oxygen order, with Unit Managers attempting to double-check compliance. However, the absence of signs persisted during the survey period. The Director of Nursing (DON) and the Administrator both acknowledged that oxygen in use signage should be posted for all residents using oxygen, whether continuously or as needed. The DON stated that the facility had run out of oxygen signs and had to order more, which contributed to the deficiency. The lack of signage was observed repeatedly for each affected resident, despite ongoing oxygen therapy and clear physician orders for its use.