Failure to Post Oxygen Safety Signage and Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents requiring oxygen therapy by not posting cautionary and safety signs indicating the use of oxygen in the residents' environments. Multiple residents with diagnoses such as chronic obstructive pulmonary disease and heart failure were observed receiving oxygen therapy via nasal cannula or concentrator, but no oxygen cautionary signage was posted near their rooms or in their immediate environment. Staff interviews revealed a misunderstanding of regulatory requirements, with both nursing and administrative staff stating that posting a sign at the facility's front entrance was sufficient due to the facility being smoke-free, and that individual room signage was not necessary. Additionally, the facility failed to maintain a clean oxygen concentrator for a resident dependent on supplemental oxygen. Observations showed that the intake filter of the resident's oxygen concentrator was caked with gray dust and debris on multiple occasions. The resident reported not knowing who was responsible for cleaning the concentrator and had not observed staff performing this task. Facility records indicated that cleaning was to be performed weekly, but the assigned nurse could not be reached for clarification. Interviews with the DON and Maintenance Director confirmed that the maintenance department was responsible for cleaning the concentrators, with nursing staff expected to monitor and report any issues. However, the Maintenance Director acknowledged that the resident's concentrator had been missed during the weekly check. The DON and Administrator both agreed that the concentrator was not clean and should not have visible dust and debris.