Failure to Post Oxygen Safety Signage and Incomplete Oxygen Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and chronic obstructive pulmonary disease. The physician's order for supplemental oxygen did not specify the required flow rate or the delivery method, such as nasal cannula, for the resident. Despite the resident receiving oxygen via nasal cannula at a flow rate of 3 liters per minute, this information was not documented in the physician's order. The DON acknowledged that the omission of the flow rate in the order was an oversight when entering the information into the electronic medical record. Additionally, the facility did not post cautionary or safety signage indicating that oxygen was in use in the resident's room, on the door, or doorframe during multiple observations. The DON confirmed that signage should have been posted according to facility process, but it was overlooked, particularly because the resident was admitted after normal business hours. The administrator also confirmed that orders should include the amount of oxygen to be administered and that cautionary signage should be posted for residents receiving supplemental oxygen.