Failure to Post Oxygen-in-Use Signage for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards by not posting required oxygen signage outside the rooms of two residents receiving oxygen therapy. One resident with dementia and heart failure had a care plan indicating oxygen therapy related to shortness of breath due to congestive heart failure, and an MDS assessment and physician order for oxygen via nasal cannula at 2–5 L/min PRN for shortness of breath. During observation, this resident was in bed with oxygen in use via nasal cannula connected to a concentrator set at 2 L/min, and there was no oxygen sign posted outside the room, despite facility policy requiring a “No smoking – Oxygen in use” sign on the patient’s door when appropriate. Another resident with chronic respiratory failure with hypoxia had a care plan indicating oxygen therapy related to chronic respiratory failure, an MDS assessment documenting oxygen therapy, and a physician order for oxygen at 2 L/min via nasal cannula every shift. Observation showed this resident in bed with oxygen in use via nasal cannula connected to a concentrator set at 2 L/min, again without an oxygen sign posted outside the room. In interviews, the ADON and the Administrator both stated that it was the facility’s expectation that oxygen signs be posted outside rooms where oxygen was being used for safety reasons, including to prevent smoking in those rooms. The facility’s written policy on nasal cannula oxygen therapy also directed staff to post a “No smoking – Oxygen in use” sign on the patient’s door when appropriate.
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