Failure to Post Oxygen Safety Signage and Obtain Timely Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen therapy policy requiring a provider order for oxygen and the posting of “oxygen in use” safety signage on door frames of rooms where oxygen is being used. The facility allows smoking by residents, staff, and visitors, yet surveyors observed that two residents receiving continuous oxygen therapy did not have cautionary signage posted on their doors. Staff interviews, including with multiple nurses and NAs, confirmed that they were aware of the policy and that signs should be posted, but they could not explain why signs were missing for these residents. One resident with COPD and acute and chronic respiratory failure had a physician’s order dated 7/22/2025 for continuous oxygen at 2 L/min via nasal cannula, and the annual MDS documented oxygen use. On multiple observations over two days, this resident was seen in bed receiving oxygen at 2 L/min without any oxygen-in-use signage on the room door. Several staff members, including nurses and NAs, acknowledged that the facility’s practice is to post oxygen signs for residents on oxygen and that such a sign should have been present, but none could account for the absence of the sign or reported having noticed it was missing. Another resident with a history of CHF and tracheostomy status was treated by an NP for hypoxia when oxygen saturations were reported in the 80s on room air. The NP stated she gave a verbal order on 3/13/2026 for continuous oxygen at 2–5 L/min via trach mask to maintain oxygen saturation at or above 90%, and expected the order to be entered into the medical record. Observations on subsequent days showed this resident receiving oxygen at 2 L/min via trach mask, including while using a wheelchair with a portable tank, but there was no oxygen order documented until 3/16/2026 and no oxygen-in-use signage on the door during those observations. The assigned nurse, the DON, and the Administrator all confirmed there was no oxygen order in the record for this period and no signage posted, and they were unable to explain why the verbal order had not been entered or why the required signs were not in place.
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