Failure to Post Oxygen in Use Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to post required cautionary signage indicating oxygen was in use for two residents who were receiving oxygen therapy. For one resident with a diagnosis of respiratory disease and a physician's order for continuous oxygen via nasal cannula, observations on multiple dates confirmed that no oxygen signage was posted on the resident's room door while the resident was receiving oxygen. Interviews with nursing staff, the hospice nurse, the Director of Nursing, and the Administrator all confirmed that signage should have been present and that nursing staff were responsible for ensuring its placement. Similarly, another resident with diagnoses including acute lower respiratory infection, cough, wheezing, and congestive heart failure was observed on multiple occasions receiving oxygen via nasal cannula without the required signage posted outside the room. Staff interviews, including with the Assistant Director of Nursing and the Director of Nursing, revealed that they were unaware the signage was missing and acknowledged that it was expected for all residents receiving oxygen to have appropriate signage posted.