Failure to Maintain Prescribed Oxygen Levels for Resident
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident reviewed for respiratory care. The resident, who was severely cognitively impaired and aphasic, had a physician's order for oxygen to be administered at 2 liters per minute via nasal cannula as needed for wheezing or shortness of breath. However, during observations, the oxygen concentrator was found running at incorrect levels of 3 liters per minute and 1.5 liters per minute on separate occasions, contrary to the physician's order. Licensed Practical Nurse (LPN) #6 confirmed that oxygen levels were set by licensed staff according to physician orders and were checked at the start of each shift. The LPN was unaware of why the concentrator was observed at incorrect settings and suggested that a Certified Nurse Aide might have accidentally adjusted the dial during care. Despite the LPN's assertion that the oxygen was set at 2 liters per minute daily, the observations indicated a failure to maintain the prescribed oxygen level, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified - Upon notification of this deficiency, resident #29's oxygen was immediately adjusted to the prescribed 2L/min. - An assessment revealed that resident #29 suffered no ill effects as a result of the deficient practice. - Resident #29 will be seen by the MD/NP for possible discontinuation of his oxygen therapy. - LPN #6 was provided re-education on the importance of ensuring that residents' oxygen devices were set to the recommendations ordered by the MD/NP. - Nurses to review and sign the flow of oxygen each shift. Residents at Risk - An audit of all residents with oxygen therapy was conducted to identify any other resident that may have been affected by this deficiency, and none were identified. - While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes - The facility reviewed Policy and Procedure Oxygen Therapy- Face Mask and Canula; no revision was needed. - Nursing staff to be in-service on the policy and procedure Oxygen Therapy- Face Mask and Canula. - The DON developed an audit tool to ensure the oxygen flow matched the doctor's order. The audit will include the residents who are on oxygen, whether nurses sign off that the correct flow is being given, and if there is a physician order [REDACTED]. Monitoring of Corrective Actions - The Director of Nursing or Designee will conduct audits daily x2 weeks, then weekly x 4 weeks, then monthly x 3 months. Any issues will be addressed immediately and reported to the administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. - The QAPI Committee will determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who required oxygen therapy for SOB had an oxygen bubbler that was overdue for replacement, despite a TAR directing weekly changes of oxygen supplies including the bubbler and tubing. Staff confirmed the bubbler should have been changed weekly, and the DON and staff educator stated nurses were expected to follow the provider order as written and that all disposable oxygen pieces were to be changed weekly.
A resident with COPD, acute respiratory failure with hypercapnia, and oxygen dependence was admitted with prior records showing nightly Bi-pap use and specific settings, but the facility did not have a Bi-pap order or settings in the chart and the baseline care plan did not address oxygen or Bi-pap. The resident reported he went without Bi-pap for three nights because a connector piece was missing, while the hospice RN, admitting LPN, ADON, and DON each stated they were unaware of the machine or did not verify the equipment and orders at admission.
Respiratory care was not provided as ordered for one resident receiving O2, as the NC tubing was not dated. Tracheostomy care was also not provided as ordered for another resident: heavy thick mucus was visible under the trach, the ATM mask was soiled with mucus, the ATM and nebulizer tubing were not dated or stored in a bag, and the suction catheter tubing end was not stored in a bag. An RN confirmed the findings.
The facility failed to follow physician orders for oxygen equipment for two residents with COPD-related diagnoses. Observations showed each resident’s O2 tubing and water bottle remained dated and unchanged beyond the ordered weekly schedule, and the DON confirmed the equipment should have been changed per the orders.
Failure to maintain ordered continuous O2: A resident with stroke and COPD was observed without his NC while a CNA waited for a portable O2 unit to be filled. The CNA then applied the NC but did not turn on the liquid portable O2, and later wheeled the resident to the nurse’s station to have the nurse set the unit to the ordered liter flow. The resident’s physician had ordered continuous O2 2L to 4L NC.
Improper Storage of CPAP Mask and Oxygen Tubing: A resident with COPD, DM, dialysis dependence, and continuous O2 orders had his CPAP/NIV mask observed lying on the bedside table and his O2 tubing wrapped under the concentrator handle instead of being stored in a sanitary container or bag. Staff interviews confirmed the equipment should be stored in a bag when not in use, but it was not being kept that way during observation.
Oxygen equipment not maintained per order
Penalty
Summary
The facility failed to ensure respiratory equipment was properly maintained for one resident who required oxygen therapy. The resident was cognitively intact, had diagnoses including multiple sclerosis and hypoxemia, and the care plan identified shortness of breath related to the diagnoses with oxygen therapy required. The August 2026 TAR directed staff to change oxygen supplies, including the oxygen bubbler and tubing, and to date and initial the change every night shift every Wednesday for routine exchange and maintenance. During observation, the resident was in bed receiving oxygen through a nasal cannula, and the oxygen PM bubbler was dated 6/4/26. RN-A stated the oxygen tubing and bubbler were supposed to be changed weekly and confirmed the bubbler date was overdue, stating it should have been changed. RN-A also stated that if oxygen supplies were not maintained properly, the chance of contracting respiratory infection increased. RN-B, who was also the staff educator, stated nurses were expected to follow provider orders as written, and the DON stated nurses should follow orders as written and that the bubbler should have been changed weekly. Facility policy stated all oxygen equipment should be clean, safe, and functional and all disposable pieces changed weekly.
Bi-pap Therapy Not Ordered or Verified at Admission
Penalty
Summary
The facility failed to ensure respiratory care was provided consistently with professional standards of practice for Resident #56, who had diagnoses including acute respiratory failure with hypercapnia, COPD, cerebral infarction, and dependence on supplemental oxygen. The resident’s prior records sent to the facility before admission documented that he required Bi-pap therapy at night for chronic hypercapnic respiratory failure, with specific settings listed, and that frequent monitoring of respiratory status, oxygen saturation, and adherence to Bi-pap therapy was critical. However, the facility’s baseline care plan did not address supplemental oxygen use or Bi-pap use, and the facility’s order summary showed oxygen at 2 to 4 liters per nasal cannula but no Bi-pap order. The resident told surveyors that he used the Bi-pap machine every night for 5 to 6 hours, but he was unable to use it for three nights because he could not find the connector piece needed to make the machine work. He stated he did not tell facility staff about the missing piece and instead told the hospice RN. During the observation, he was sitting in a wheelchair on oxygen at 3 liters per nasal cannula, with even and unlabored respirations and no shortness of breath. Nursing notes during the stay documented oxygen saturations ranging from 94% to 98% while on oxygen, but the records did not show a Bi-pap order or settings in the hospice orders. Interviews showed that the hospice RN who admitted the resident was not aware he had a Bi-pap machine and did not see it in the facility, and she did not review the DME section of the chart. The admitting LVN and ADON both stated they were unaware of the Bi-pap machine or its missing order/settings, and neither checked whether the equipment was present and working at admission. The DON stated she assumed hospice would write the Bi-pap order and later learned there were no orders for the machine. The Administrator stated the admission nurse was responsible for verifying equipment was in proper working condition and that all needed services and orders were administered. The facility policy on CPAP/Bi-pap described how to use the machine and to contact the DME company if it was not operating correctly, but it did not indicate that orders were required.
Respiratory Care and Tracheostomy Care Not Provided as Ordered
Penalty
Summary
Respiratory care was not provided consistent with professional standards of practice for a resident receiving oxygen. The resident had diagnoses including depression, low blood pressure, and atrial fibrillation, and the MDS indicated oxygen therapy while a resident. During observation, the resident was lying in bed with oxygen on, and the nasal cannula was not dated. The physician order required oxygen at 3 liters per minute via nasal cannula at night or as needed, and another order directed that the oxygen concentrator and filter be cleaned and the tubing changed weekly. During interview, the RN confirmed that the oxygen tubing did not have a date on it and confirmed the facility failed to provide appropriate respiratory care for the resident. Tracheostomy care was also not provided consistent with professional standards of practice for another resident. The resident had diagnoses including diabetes, heart failure, and stroke. Physician orders directed staff to check that the trach mask and oxygen were in place and to assess the need for suctioning, trach care, and oral care four times a day. The care plan directed suctioning of the trach and oral care every shift and every two hours as needed, and to provide oxygen via aerosolized trach mask with tubing and filters changed weekly. During observation, the resident was connected to oxygen via ATM, but heavy thick mucus was visible under the trach, the inside of the trach mask was soiled with mucus, the ATM tubing and nebulizer tubing were not dated, and the tubing was not stored in a bag as required. The suction catheter tubing end was also not stored in a bag as required, and the RN confirmed these findings during interview.
Failure to Change Oxygen Equipment per Physician Orders
Penalty
Summary
The facility failed to maintain respiratory equipment according to physician orders for two residents receiving oxygen therapy. Resident R18 had diagnoses including chronic respiratory failure, COPD, and hypertension, and had an order dated 10/20/25 to change the O2 tubing, water bottle, and tubing bag weekly every Sunday night shift. Resident R20 had diagnoses including COPD, GERD, and hypothyroidism, and also had the same weekly order for oxygen tubing, water bottle, and tubing bag. Facility policy stated medications are to be administered in accordance with written physician orders. On 8/4/26 and again on 8/5/26, observations showed both residents’ oxygen concentrators with water bottles and O2 tubing dated 7/27/26. The dated equipment remained unchanged during the second observation. During interview on 8/5/26, the DON confirmed that both residents’ water bottles and oxygen tubing were dated 7/27/26 and should have been changed per physician orders.
Failure to Maintain Ordered Continuous Oxygen
Penalty
Summary
The facility failed to ensure that Resident #6 received continuous oxygen via nasal cannula as ordered by the physician. The facility’s Oxygen Administration policy dated February 2024 stated staff were to verify a physician’s order and place the appropriate oxygen device on the resident, with oxygen started at the ordered flow rate. Resident #6 was admitted and later readmitted to the facility with diagnoses including stroke and COPD, and the physician’s order dated 6/25/26 specified oxygen 2L to 4L NC continuous. On 8/3/26 at 10:17 AM, Resident #6 was observed sitting in a wheelchair in his room without his oxygen cannula on while CNA #1 stood next to him. CNA #1 stated he was taking Resident #6 out of the room but was waiting for the portable oxygen unit to be filled. When the liquid oxygen unit arrived, CNA #1 attached the tubing and applied the nasal cannula but did not turn on the portable oxygen unit. At 10:26 AM, CNA #1 wheeled Resident #6 to the nurse’s station and waited for the nurse to turn the portable oxygen on to the resident’s liter flow. The resident’s care plan documented oxygen as ordered and to check room air saturation as ordered, wean as able/ordered. On 8/4/26 at 4:40 PM, the RNC stated the CNA should not have taken Resident #6 off oxygen and should have had the nurse set the liquid portable unit to the proper liter flow before placing it on the resident.
Improper Storage of CPAP Mask and Oxygen Tubing
Penalty
Summary
The facility failed to ensure Resident 10’s CPAP/NIV mask and oxygen tubing were stored in a sanitary manner. Resident 10 had diagnoses including DM, COPD, dialysis dependence, and dependence on supplemental oxygen. His record included physician orders for NIV use at night with oxygen at 3 LPM connected to the device, and oxygen at 3 LPM via nasal cannula after the mask was removed in the morning. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and his care plan included staff assistance with respiratory equipment as ordered. During observation, the resident’s NIV mask was seen lying directly on the bedside table next to the machine rather than in a container. On another observation, the resident’s oxygen tubing was wrapped together and placed under the handle of the oxygen concentrator instead of being stored in a container. A CNA stated she would transfer the oxygen tubing from the concentrator to the portable oxygen tank after getting the resident up and then place the tubing inside the concentrator handle. An LN stated the CPAP mask and oxygen tubing should be stored in a bag when not in use, and an Administrative Nurse stated the respiratory equipment should be cleaned and changed as ordered and stored in the dated bag.
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