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F0695
D

Oxygen Therapy Administered Without Physician Order

Webster, Massachusetts Survey Completed on 07-30-2025

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 provide respiratory care and services in accordance with professional standards of practice for one resident. Specifically, a resident with diagnoses including Chronic Kidney Disease, Obstructive Sleep Apnea, Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease was observed receiving oxygen therapy at 4 liters per minute via nasal cannula. The resident reported always using oxygen at this rate, and the oxygen concentrator was observed in use during the survey. Upon review of the resident's medical record, there were no physician orders in place for the administration of oxygen therapy. Nursing staff and the Director of Nursing confirmed that oxygen was being administered without a physician's order, despite facility policy requiring all medications and treatments, including oxygen, to have a physician's order. The lack of a physician order for ongoing oxygen therapy constituted a failure to follow professional standards and facility policy.

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