Failure to Post Oxygen Cautionary Signs for Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to post cautionary signs indicating oxygen use for a resident who required respiratory care. Record review showed that the resident was admitted with chronic obstructive pulmonary disease and chronic respiratory failure, and had a physician's order for oxygen at 2 liters per minute via nasal cannula. Observations on two separate occasions revealed that the resident was receiving oxygen therapy in their room, but there were no cautionary oxygen signs posted near the entrance to the room. Interviews with staff confirmed that nursing was responsible for posting these signs, and that the signs had not been replaced following recent renovations. The Director of Nursing was unaware that the required signage was missing for residents with oxygen orders.