Failure to Post Oxygen Signage for Resident Receiving Supplemental Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to post cautionary oxygen signage at the entrance to a resident’s room while supplemental oxygen was in use. The resident had systolic congestive heart failure and severely impaired cognition, and had physician orders for PRN supplemental oxygen via nasal cannula at 2 L/min to maintain oxygen saturation above 90%. On multiple observations on one survey date, the resident was seen in bed receiving oxygen via nasal cannula, yet there was no oxygen signage on or near the room entrance. A general “No Smoking” sign was posted at the facility’s main entrance, but it did not indicate that supplemental oxygen was in use within the facility or specifically for this resident’s room. Further review of the electronic medical record showed the resident had been sent to the hospital and then readmitted, with new orders again for PRN supplemental oxygen at 2 L/min. On a subsequent observation date, the resident was again noted in bed with oxygen via nasal cannula and still no oxygen signage at the room entrance. Interviews with the DON, Administrator, Regional Nurse Consultant, Medical Records/Central Supply clerk, a hall nurse, and a Unit Manager revealed inconsistent and unclear understanding of who was responsible for ensuring oxygen signage was posted when a resident used supplemental oxygen. Staff members variously believed responsibility lay with Medical Records/Central Supply, nursing staff, the hall charge nurse, or the Unit Manager, and there was no clear process identified for residents who began oxygen use without advance notice or after new oxygen orders were written.
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