F0695

D

Failure to Follow Oxygen Orders and Ensure Proper Oxygen Administration

Lancaster, California Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and physician orders for a resident with COPD and acute and chronic respiratory failure with hypoxia. The resident was admitted with diagnoses including unspecified COPD, orthopedic aftercare, and acute and chronic respiratory failure with hypoxia. An H&P dated 12/19/2025 documented that the resident did not have capacity to understand and make decisions, while an MDS dated 12/25/2025 indicated intact cognitive skills for daily decisions and a need for staff supervision with hygiene, toileting, and showering. Initial physician orders on 12/19/2025 directed oxygen at 4 L/min via nasal cannula, continuous with humidification for COPD and shortness of breath every shift, and a subsequent order dated 1/14/2026 changed the oxygen to 2 L/min via nasal cannula continuously every shift.

On observation on 1/29/2026 at 9:19 a.m., the resident was found asleep at bedside with an oxygen concentrator running at 5 L/min via nasal cannula, but the nasal cannula was not connected to the resident and was instead hanging on a portable emergency light on top of the resident’s rolling table. A concurrent observation and interview with an RN confirmed that the oxygen was running at 5 L/min and that the nasal cannula was not attached to the resident. The RN called an LVN to obtain a pulse oximeter reading. At 9:25 a.m., the LVN placed the pulse oximeter on the resident’s left index finger, which showed an oxygen saturation of 92%, then reconnected the nasal cannula to the resident. The LVN stated that the resident’s oxygen saturation fluctuated between 80% and 90% while on 5 L/min, and the resident subsequently awoke, coughed up white phlegm, and the oxygen saturation increased to 91%.

During interviews and record reviews, the ADON confirmed that the physician’s order dated 1/14/2026 specified oxygen at 2 L/min via nasal cannula and stated that a physician order was required to increase or titrate the oxygen, and there was no such order in place. The ADON stated that a resident not connected to ordered oxygen could experience shortness of breath. The LVN reported having observed the resident’s oxygen set at 5 L/min and acknowledged that the resident had a history of COPD and that giving high oxygen can cause shortness of breath. The DON stated that nurses should follow the physician’s order for continuous oxygen at only 2 L/min and that higher oxygen administration could result in hyperventilation. Review of facility policies showed that medications, including oxygen, must be administered in accordance with prescriber orders and that oxygen administration procedures require ensuring the proper flow of oxygen is being administered, which was not followed in this case.