Failure to Post Oxygen Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care were provided with appropriate safety measures, specifically the posting of oxygen in use signage on the doorways of two residents who were receiving oxygen therapy. Both residents had documented diagnoses of chronic obstructive pulmonary disease (COPD) and physician orders for oxygen administration via nasal cannula. Observations confirmed that each resident was using oxygen, either through a concentrator or portable tank, and that no oxygen signage was posted outside their respective rooms as required by facility policy. Interviews with staff, including an LVN and the DON, confirmed that it was the facility's expectation to have oxygen signs posted on the doors of rooms where oxygen was in use. The DON acknowledged the absence of the signs and stated that they are typically posted for resident safety, suggesting the signs may have fallen off. The facility's policy on oxygen administration also specified the need for appropriate oxygen signage. The lack of signage was observed during multiple walkthroughs and confirmed by both staff and administrative personnel.