F0695

D

Failure to Follow Oxygen Safety Signage and Prescribed Flow Rates

Fredericksburg, Virginia Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

Facility staff failed to provide safe and appropriate respiratory care for two residents receiving oxygen therapy. For one resident with a physician’s order for oxygen at two liters per minute for shortness of breath, surveyors twice observed the resident in bed on oxygen via nasal cannula and concentrator without any cautionary or safety signage indicating oxygen use at the doorway or in the room. An LPN stated that when a resident is receiving oxygen, a sign is supposed to be posted outside the room door to alert staff that the resident requires oxygen and because oxygen is flammable. Facility policy on oxygen administration documented that oxygen is considered a fire hazard and that “Oxygen in Use” signage should be posted where applicable.

For another resident with a physician’s order for oxygen at two liters per minute for chronic obstructive pulmonary disease, surveyors observed the oxygen concentrator flow meter set above the ordered rate on two occasions. The first observation showed the ball in the flow meter between the three- and four-liter lines, and the second observation showed the ball between the two- and three-liter lines, while the concentrator was not within the resident’s reach during either observation. The LPN interviewed stated that nurses should check the physician’s order and verify the correct oxygen amount by viewing the flow meter at eye level and ensuring the middle of the ball runs through the prescribed line. The manufacturer’s instructions for the concentrator specified that the flow should be adjusted until the ball is centered on the line marking the specific flow rate, and the facility’s oxygen administration policy required verification of the physician’s order prior to initiation and application of the prescribed flow rate.