Failure to Post Oxygen-In-Use Safety Signage for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care by not posting cautionary and safety signage indicating oxygen use for three residents receiving oxygen therapy. One resident with Streptococcus pyogenes had a physician order for continuous oxygen via nasal cannula at 2 liters per minute (lpm) to maintain oxygen saturation above 90%, and the resident’s MDS documented oxygen use. Multiple observations over several days showed this resident in bed with oxygen at 2 lpm and no cautionary or safety signage posted at the room. Another resident with chronic obstructive pulmonary disease (COPD) had a physician order for oxygen at 2 lpm via nasal cannula, and observations on several occasions found the resident in the room using oxygen without any oxygen-in-use signage posted. A third resident with COPD had physician orders for continuous oxygen via nasal cannula at 2 lpm to keep oxygen saturation above 90%, and the MDS also documented oxygen use. Observations on multiple dates and times showed this resident in bed receiving oxygen at 2 lpm with no cautionary or safety signage at the room. During interviews, a nurse aide stated she did not recall ever seeing oxygen-in-use signs on residents’ doors and learned which residents were on oxygen only during shift report, and a nurse reported not seeing any oxygen-in-use signs posted in the facility. The DON stated that precaution signs for oxygen were not needed because the facility was smoke free, and the Administrator similarly stated that with no smoking signs posted throughout the campus and being a smoke-free facility, there was no need for oxygen cautionary signs on residents’ doors.
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