Failure to Post Oxygen in Use Signage Outside Resident Rooms
Penalty
Summary
Surveyors found that the facility failed to post cautionary and safety signage outside the rooms of three residents who were receiving oxygen therapy. Each of these residents had physician orders for oxygen administration due to chronic or acute respiratory failure with hypoxia, and observations confirmed that oxygen was actively being administered via nasal cannula during multiple surveyor visits. Despite this, there were no signs posted at the entrances to these residents' rooms to indicate that oxygen was in use. Interviews with facility staff, including a nursing assistant, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, revealed that the facility did not have a practice of posting oxygen in use signage at individual resident rooms. The DON and Administrator stated that because the facility was non-smoking and had no smoking signs posted at entrances and exits, they believed it was not necessary to post oxygen in use signs at resident rooms. This practice was confirmed by staff and observed by surveyors during their visits.