Failure to Post Oxygen Use Signage for Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy and tracheostomy management. Specifically, the facility did not ensure that cautionary and safety signs indicating oxygen use were posted outside the resident's room, despite the resident receiving oxygen via nasal cannula connected to an oxygen concentrator at 2 LPM with a capped tracheostomy. Observations confirmed the absence of required signage, and interviews with staff revealed there was no designated individual responsible for ensuring oxygen signage was posted. The resident involved was admitted with a primary diagnosis of cerebral infarction and secondary diagnoses including chronic respiratory failure with hypoxia and tracheostomy status. Facility policy required "No Smoking" signs to be placed in areas where oxygen was administered or stored, but this was not followed. Both the ADON and DON acknowledged their responsibility for ensuring proper signage and recognized the risks associated with the lack of oxygen use indicators, such as the potential for staff to inadvertently use flammable substances or electrical appliances near the oxygen source.