Failure to Ensure Proper Oxygen Signage and Physician Orders
Penalty
Summary
Surveyors found that the facility failed to ensure proper respiratory care for residents requiring oxygen therapy. Specifically, two residents were observed receiving oxygen without the required signage indicating oxygen use at the entry to their rooms, as mandated by facility policy. One resident with diagnoses including emphysema, COPD with acute exacerbation, and respiratory failure was observed using oxygen at two liters per minute via nasal cannula, but there was no sign posted to indicate oxygen was in use. This was confirmed by an LPN, and the facility's policy required such signage. Another resident was observed twice receiving oxygen via nasal cannula from a concentrator, also without any oxygen safety sign displayed in the room or on the doorway, which was confirmed by an RN. Additionally, review of the medical record for the second resident revealed that there was no active physician order for oxygen administration, despite the resident receiving oxygen. This was verified by an LPN. The facility's policy required checking for a physician's order for oxygen administration and posting an oxygen in use sign. The lack of signage and absence of a physician order for oxygen administration were identified as deficiencies during the survey.