Failure to Maintain and Label Oxygen Equipment and Post Oxygen Safety Signage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and storage policy regarding equipment labeling and oxygen safety signage for multiple residents receiving oxygen therapy. The policy, revised 3/8/2022, requires staff to label tubing connected to oxygen concentrators with the time and date of change and to place an “Oxygen in Use” sign on the resident’s door or door frame. Surveyors observed several residents on oxygen without required door signage: one resident with chronic respiratory failure with hypercapnia, COPD, panlobular emphysema, atrial fibrillation, chronic kidney disease, hypertension, depression, and anxiety was receiving 2–4 L/min oxygen by nasal cannula every shift with no oxygen sign on the door; another resident with bipolar disorder, obsessive-compulsive personality disorder, and asthma, with an order for 2 L/min oxygen by nasal cannula as needed and a care plan indicating oxygen therapy, was also on oxygen without door signage; and a third resident with COPD, asthma, and shortness of breath, ordered 2–4 L/min oxygen by nasal cannula every shift and care planned for oxygen related to COPD and asthma, was similarly observed on oxygen without an oxygen sign on the door. The DON later confirmed that residents using oxygen should have a sign posted outside their room and acknowledged that these residents did not. Additional deficiencies were identified in the maintenance and labeling of oxygen equipment. One resident was observed sitting on the edge of the bed with oxygen via nasal cannula, and the oxygen tubing and humidity bottle were not dated; the resident stated she did not think anyone checked the oxygen and did not know how staff would be alerted if the tank ran out. The DON confirmed that oxygen tubing and humidity bottles should be dated when changed and stated they are supposed to be changed weekly with a label indicating the date of change. Another resident with obstructive sleep apnea, COPD, and shortness of breath had an oxygen machine in the room with unlabeled oxygen tubing and a humidification bottle dated 1/2/2026 on two separate observations. A CNA confirmed the absence of a label on the tubing and the date on the humidification bottle, and the ADON confirmed that all oxygen tubing should be dated and that humidification bottles and tubing should be changed weekly. These observations and interviews demonstrate that the facility did not consistently maintain and label oxygen equipment or post required oxygen safety signage in accordance with its policy for residents receiving oxygen therapy.
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