Failure to Post Oxygen in Use Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
Staff failed to post an 'Oxygen in Use' sign on the door of a resident who was receiving continuous supplemental oxygen therapy as ordered by a physician for hypoxia related to pneumonia. The resident had a history of pneumonia, sleep apnea, congestive heart failure, and hypoxia, and was assessed as having moderate cognitive impairment. Observations on two separate occasions confirmed that the required signage was not present while the resident was receiving oxygen via nasal cannula in their room. Interviews with the DON and Administrator confirmed that facility policy and their expectations required an oxygen-in-use sign to be posted whenever a resident was started on oxygen therapy. Review of the facility's oxygen therapy policy also indicated that increased oxygen concentrations present a fire hazard, underscoring the importance of proper signage. Despite these policies and expectations, the sign was not posted as required.