Failure to Post Oxygen Sign for Resident Receiving Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to post an oxygen sign outside the room of a resident receiving oxygen therapy, contrary to facility policy and staff expectations. Record review showed the resident was an elderly female with Alzheimer’s disease, dementia, COPD, asthma/chronic lung disease, and allergic rhinitis, with an admission date of 07/21/2018. Her annual MDS dated 01/05/2026 documented a BIMS score of 0, indicating severe cognitive impairment, and active diagnoses including asthma and COPD/chronic lung disease. The resident’s care plan dated 01/13/2026 included interventions for oxygen therapy, specifying oxygen administration at 2 L/min via nasal cannula as needed for oxygen saturation at or below 90%, along with monitoring of respiratory status and interventions to support adequate oxygenation. On 03/27/2026 at 11:29 a.m., observation in the resident’s room found her asleep in bed, wearing a nasal cannula, with the oxygen concentrator turned on. Despite active oxygen use, there was no oxygen sign posted outside the resident’s room. Multiple staff interviews confirmed that the facility’s practice and expectations were that oxygen or “No Smoking/Oxygen in Use” signs be posted outside any room where oxygen therapy or an oxygen concentrator was present. CNA A, CNA B, LVN C, LVN D, the social worker, the DON, and the Administrator each stated that oxygen signs were required outside rooms with oxygen concentrators to alert staff and visitors, and they described potential negative outcomes such as staff not monitoring oxygen levels or fire hazards. Review of the facility’s undated Oxygen Administration policy stated that “No Smoking” signs should be placed in the area when oxygen is administered and stored, and that if the facility is non‑smoking, oxygen in use signs are not required on individual resident rooms. Despite this, facility leadership and staff consistently indicated that oxygen signs should be posted outside rooms with oxygen concentrators, and on the date of observation, no such sign was posted for this resident while oxygen was in use.
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