Failure to Post Oxygen Safety Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to post cautionary and safety signage outside the rooms of residents who were receiving oxygen therapy. This deficiency was identified for 13 out of 36 residents reviewed for respiratory care. Multiple observations confirmed that residents were either actively receiving oxygen via nasal cannula or had oxygen equipment present in their rooms, yet there was no signage at the entrance to indicate that oxygen was in use. The absence of such signage was consistent across several residents, regardless of whether the oxygen was being administered continuously, as needed, or only at night. Specific examples included residents with physician orders for continuous or as-needed oxygen therapy, who were observed with oxygen concentrators running or oxygen tubing in place, but without any cautionary signs posted on their doors. In some cases, the oxygen concentrator was present in the room but not running at the time of observation, yet the signage was still missing. The deficiency was observed on multiple occasions for each affected resident, indicating a pattern rather than isolated incidents. Interviews with staff, including nurses, the DON, and the Administrator, revealed a lack of clarity regarding responsibility for posting the required signage. Some staff members were unaware of who should apply the signs, while others believed it was the responsibility of the person bringing the concentrator into the room, but ultimately all staff were expected to ensure signage was in place. The Administrator acknowledged that she had not noticed the absence of signage and agreed that it should be present for all residents prescribed oxygen.