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F0695
E

Failure to Follow Physician Orders for Oxygen Administration

Santa Clara, California Survey Completed on 05-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow professional standards of practice for oxygen administration for three residents. One resident was observed receiving oxygen at a flow rate higher than the physician's order, with the nasal cannula set between 2.5 and 3 liters per minute (LPM) instead of the ordered 2 LPM. Another resident was administered oxygen at 4 LPM without any physician's order for oxygen therapy, as confirmed by both observation and review of the resident's medical orders. A third resident, who had multiple diagnoses including spinal cord injury, diabetes, chronic kidney disease, myelofibrosis, and anemia, was observed receiving oxygen at 4 LPM, while the physician's order specified 2 LPM. In each case, staff acknowledged the discrepancies between the administered oxygen and the physician's orders. The facility's policy and procedure for oxygen administration requires staff to check the physician's order for the correct liter flow and method of administration. Despite this, staff failed to ensure that oxygen was administered according to the prescribed orders for these residents. The Director of Nursing confirmed that oxygen orders should always be followed, and staff interviews further verified that the observed oxygen administration did not match the documented orders.

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