Failure to Provide Routine Oxygen Therapy and Required Safety Signage
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents who were receiving oxygen therapy. For one resident with diagnoses including acute respiratory failure with hypoxia, end stage renal disease, and heart failure, the physician's order specified routine oxygen therapy at three liters per minute via nasal cannula with a goal oxygen saturation above 92%. However, the resident was not consistently receiving routine oxygen therapy as ordered, and the oxygen saturation summary indicated only intermittent use. Additionally, there was no signage posted in the resident's room to indicate oxygen was in use, contrary to facility policy and safety protocols. For another resident with chronic obstructive pulmonary disease, dependence on supplemental oxygen, and atherosclerosis, the physician's order required routine oxygen therapy at two liters per minute via nasal cannula, with titration to maintain oxygen saturation above 92%. Observations revealed that this resident's room also lacked the required signage indicating oxygen use. Both the LVN and the DON confirmed that facility policy required a 'No Smoking/Oxygen in Use' sign to be posted outside the rooms of residents receiving oxygen therapy, and acknowledged that the absence of such signage was a safety hazard. Review of facility policies confirmed that 'No Smoking/Oxygen in Use' signs are necessary equipment when administering oxygen. The DON and LVN both stated that staff were not following physician's orders for routine oxygen therapy and were not adhering to facility policy regarding safety signage. These failures were identified through observation, interview, and record review, and were not in accordance with the facility's established procedures for oxygen administration.