Failure to Provide Necessary Respiratory Care
Summary
The facility failed to provide necessary respiratory care and services, including oxygen administration, to a resident who required such care. The resident, who had a history of heart failure, morbid obesity, diabetes mellitus, and atrial fibrillation, was admitted with a verbal order for oxygen administration. However, this order was not documented, verified, or communicated to the staff, leading to a lack of proper implementation. As a result, the resident ambulated without oxygen, experienced a fall, became unresponsive, and subsequently died. Interviews and record reviews revealed that the resident was on PRN oxygen, but there was no formal order documented in the facility's records. The nursing staff, including the RN, LVN, and DON, were unsure about the existence of an oxygen order, and the necessary documentation was missing from the electronic health record. The resident's care plan indicated a risk for shortness of breath, but the order summary report and NEMAR did not reflect any order for oxygen administration. The deficiency was further compounded by the lack of communication and verification of the resident's needs during the admission process. The admitting nurse failed to enter the oxygen order into the computer, and subsequent chart audits did not catch this oversight. The facility's failure to ensure proper documentation and communication of the resident's oxygen needs placed the resident at risk of respiratory distress, ultimately leading to the resident's death.
Removal Plan
- Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community on continuous oxygen and verified accurate orders were in the electronic health record.
- Director of Nursing Services/Assistant Director of Nursing Services provided education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility.
- Director of Nursing Services/Assistant Director of Nursing Services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders.
- Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen.
- Director of Nursing/Assistant Director of Nursing will provide education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing.
- Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services.
- Director of Nursing/Assistant Director provided education to all licensed nurses in regard to resident's changes in condition.
- Director of Nursing/Assistant Director provided education to all direct care team members on use and access of the Kardex.
- Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility.
- Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift.
- Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift.
- Director of Nurses/Assistant Director of Nurses will conduct skills validations of order entry.
- Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders in the clinical meeting.
- Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting.
- Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with random therapy team members.
- Director of Nursing Services/Assistant Director of Nursing Services will validate the proper process of use/access of the Kardex by direct care staff.
- Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from random licensed nurses.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents receiving O2 had flow rates set above their physician orders, and one resident’s tubing remained dated beyond the weekly change interval. Staff, including an RN and the DON, confirmed the mismatched flow rates and noted that tubing should be changed weekly by the RT. The facility policy required O2 to be administered per physician order and tubing/cannula to be changed weekly.
Oxygen Concentrator Left in Room After Order Discontinued: A resident with morbid obesity with alveolar hypoventilation and diabetes was observed with an oxygen concentrator at bedside even though there was no current oxygen order. The resident stated he used oxygen only when needed, and the CNO confirmed the oxygen had been discontinued earlier and the concentrator should not have remained in the room.
Missing Order for CPAP Use and Maintenance: A resident with sleep apnea and stroke had a CPAP in the room, but there was no physician order or care plan documentation for its use or maintenance. Staff knew the resident had the CPAP, yet CNAs and an RN reported they did not routinely clean the mask or tubing, and the LPN Resident Care Manager confirmed no order existed for the CPAP or its care.
A resident with a continuous O2 order was found without oxygen in place, and an LPN later said the order had been misread. Two other residents with COPD had respiratory equipment that was dirty or outdated, including a gray concentrator filter, tubing and water bottles dated weeks earlier, and tubing lying on the floor with visible dust. Staff gave inconsistent accounts of who was responsible for changing or cleaning the equipment, and the DON acknowledged the dirty equipment and old mask placed residents at risk for respiratory infection or pneumonia.
A resident with acute respiratory failure with hypoxia and severe cognitive impairment was ordered oxygen via NC at 2 to 5 LPM to keep O2 saturation at or above 95%. During observation, the resident was lying in bed with the NC on the side of the face instead of in the nose while the concentrator was set at 2.5 LPM. RN and DON stated the NC should be in the nose to deliver oxygen as ordered.
A resident with COPD and chronic respiratory failure did not receive oxygen at the ordered flow rate. Staff found the oxygen concentrator set below the ordered amount on multiple observations, and the resident stated the oxygen was supposed to be set higher. The DON, LVNs, and ADON acknowledged the setting was incorrect and that the ordered flow should have been followed.
Incorrect Oxygen Flow Rates and Delayed Tubing Changes
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for two residents receiving oxygen therapy. Resident #5 had an order dated 1/7/2025 for oxygen at 2 liters via nasal cannula continuously for infiltrate of the left lung, but during observations on 7/7/2026, 7/8/2026, and 7/9/2026 the resident’s oxygen was running at 3 liters per minute. On 7/7/2026 and 7/8/2026, the oxygen tubing in Resident #5’s room was dated 6/26, and on 7/9/2026 Staff F, RN confirmed the tubing date and the 3-liter flow rate. Staff F stated the tubing should have been changed the prior week and that the resident was running at 3 liters despite an order for 2 liters. Resident #6 had a physician order dated 3/18/2026 for oxygen at 3 liters via nasal cannula continuously for chronic respiratory failure with hypoxia, but during observations on 7/7/2026 at 10:10 AM and 12:12 PM, and again on 7/8/2026 at 8:02 AM, the resident’s oxygen was being administered at 4 liters per minute. On 7/9/2026 Staff F, RN entered the room and confirmed the oxygen was at 4 liters, stating it should not be at that rate because the order was for 3 liters. The DON stated nursing staff should check oxygen flow rate every shift and as needed, and that tubing should be changed weekly by the respiratory therapist. The facility policy also stated oxygen tubing and mask/cannula are to be changed weekly and as needed if soiled or contaminated.
Oxygen Concentrator Left in Room After Order Discontinued
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to remove an oxygen concentrator from Resident #12's room after the physician discontinued the oxygen order. Resident #12 was admitted and later readmitted to the facility with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. On 7/7/26, the resident was observed sitting in his power chair with an oxygen concentrator at his bedside. When asked about oxygen use, the resident stated he only used oxygen when he needed it. Review of the resident's physician orders showed no current oxygen order, and the CNO stated on 7/8/26 that the oxygen concentrator should not have been in the room because oxygen had been discontinued on 6/17/26.
Missing Order for CPAP Use and Maintenance
Penalty
Summary
The facility failed to obtain physician orders for the use and maintenance of a CPAP for Resident 76, who was admitted in 6/2026 with diagnoses including sleep apnea and stroke. There was no documentation in the admission MDS or care plan showing that the resident used a CPAP. Observations from 7/6/26 through 7/10/26 showed the CPAP in the resident’s room on the nightstand. The resident stated that a friend brought the CPAP to the facility a day after admission, but staff did not clean the mask or tubing daily and the mask did not fit well. Staff interviews showed the CNA staff were aware of the CPAP but did not clean the mask or hose, one CNA reported washing the mask one time, and an RN stated she filled the chamber with water a few times but did not clean the mask or tubing. The LPN Resident Care Manager confirmed the resident did not have an order for the CPAP or for cleaning and caring for the equipment.
Respiratory Equipment Not Maintained or Applied as Ordered
Penalty
Summary
Resident #12 had an order for oxygen at 2 liters per minute via nasal cannula continuously, with titration up to 4 liters to keep oxygen saturations above 90% every shift. The resident’s care plan also directed staff to apply oxygen at 2 liters via nasal cannula. During an observation, the resident was up in a chair with no oxygen in place. The resident stated she had been wearing oxygen but was not sure when or why staff stopped applying it. The nurse later stated she had misread the order as oxygen could be applied only if saturations fell below 90%, and she acknowledged the resident did not wear oxygen despite the active continuous order. Resident #27 had diagnoses including dementia, COPD, anxiety, and shortness of breath, and her MDS indicated she required oxygen therapy. Her care plan directed staff to change oxygen tubing as needed and nebulizer tubing every week. During multiple observations, the resident’s oxygen concentrator filter was gray and dirty, and the tubing and empty water bottle were dated 5/24/26. The resident stated staff usually changed the equipment, but it had not been changed that she could recall. Later, the tubing and water bottle remained dated 5/24/26, and the concentrator filter was still dirty. Staff interviews reflected uncertainty about who was responsible for changing the equipment, and the ADON stated the tubing and water bottle should have been changed by 07/02/26, while the DON stated the dirty filter and old nebulizer mask placed the resident at risk for respiratory infection or pneumonia. Resident #9 had COPD and an order for oxygen at 2 to 4 liters per nasal cannula to maintain PO2 greater than 90%. The resident’s oxygen tubing was observed lying on the floor and had a piece of tape dated 06/22/26, with brown dust visible in the wheel-mark pattern on the tubing. The resident was unable to state when the tubing was last changed or how often it was changed. Staff interviews showed differing practices about changing oxygen tubing, with some stating it should be changed weekly or when dirty, while the DON stated she had been advised not to date the tubing and to change it when visibly soiled. The facility policy stated cannula or mask needed to be changed if it malfunctions or becomes visibly contaminated.
Oxygen Not Properly Delivered via Nasal Cannula
Penalty
Summary
The facility failed to ensure oxygen was administered in accordance with the physician’s order and facility policy for one sampled resident. Resident 44 was admitted with diagnoses including acute respiratory failure with hypoxia and encephalopathy. The MDS dated 5/28/2026 indicated the resident had severe cognitive impairment, was on oxygen therapy, and was dependent for eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. A physician’s order dated 6/4/2026 directed oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift, and the care plan was revised to reflect humidified oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift. During a concurrent observation on 6/29/2026 at 10:33 AM, Resident 44 was observed lying in bed with the nasal cannula on the left side of the face while the oxygen concentrator was set at 2.5 LPM. During interviews, RN 3 stated the nasal cannula should be placed correctly in the resident’s nose for the resident to receive oxygen, and the DON stated the nasal cannula should always be in the resident’s nose to help maintain oxygen saturation at 95% and above. The facility policy titled Oxygen Administration stated oxygen is administered to residents who need it, consistent with professional standards of practice and comprehensive person-centered care plans, and under physician orders.
Incorrect Oxygen Flow Settings
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with COPD, chronic respiratory failure, and functional quadriplegia. The resident’s care plan directed that oxygen be administered at 2 L/min via nasal cannula continuously to maintain SPO2 above 90%, and the physician order summary reflected oxygen at 2 L/min via nasal cannula continuously. However, during observation and interview on 06/30/2026, the resident’s oxygen concentration machine was set at 3 L/min, and the resident stated her oxygen was supposed to be set at 4 L/min. The LVN stated the resident was supposed to be on 4 L/min and adjusted the oxygen to 3.5 L/min, and the DON later stated the resident was to be getting 4 L/min and adjusted the setting to 4 L/min. A subsequent physician order dated 07/01/2026 directed oxygen at 4 L/min via nasal cannula to maintain SPO2 above 90%. During observation on 07/02/2026, the resident’s oxygen was again found set at 3.5 L/min. An LVN checking the setting stated it was at 3.5 L/min and that if physician orders were not followed, the resident could become short of breath and the orders would not be followed. The ADON stated the oxygen machine should be set with the ball meter at eye level, that if the order said 4 L/min it should be set on 4 L/min, and that 3.5 L/min was not good enough. The facility’s oxygen administration policy required verifying a physician order and adjusting the oxygen delivery device so the proper flow of oxygen was being administered.
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