Failure to Post Required Oxygen Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure that residents requiring oxygen therapy had appropriate oxygen signage posted outside their rooms, as required by the facility's own policy. Observations, interviews, and record reviews revealed that six residents who were receiving oxygen therapy did not have 'No Smoking' or oxygen signs posted on their room doors. Each of these residents had physician orders and care plans specifying the use of oxygen via nasal cannula at various flow rates to maintain adequate blood oxygen saturation levels. During observations, all six residents were noted to be receiving oxygen therapy in their rooms without the required signage present. The residents involved had significant medical histories, including diagnoses such as heart failure, respiratory failure, COPD, pulmonary fibrosis, and nicotine dependence. Their cognitive statuses ranged from severely impaired to relatively intact, as indicated by their BIMS scores. Despite the presence of oxygen equipment in use, there was no visual indication on the room doors to alert staff or visitors to the presence of oxygen, which is a standard precaution outlined in the facility's oxygen therapy policy. Interviews with facility leadership revealed a lack of clarity and accountability regarding the responsibility for posting oxygen signs. The DON acknowledged that there was no designated staff member assigned to ensure the signs were placed, and the administrator was unaware that the facility policy required signage on individual resident doors, mistakenly believing that a sign at the front entrance was sufficient. Review of the facility's oxygen therapy policy confirmed the requirement to post 'No Smoking' signs on the outside of doors to rooms where residents are receiving oxygen.