F0695

D

Failure to Clarify and Implement Oxygen Order for Resident With COPD

Los Angeles, California Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide respiratory care and services consistent with professional standards of practice for a resident with COPD and other respiratory disorders. During an observation in the resident’s room, the resident was seen sitting in a wheelchair without oxygen in use, and there was no oxygen concentrator or tubing present. The resident reported having COPD, sometimes experiencing shortness of breath, and stated that since being readmitted to the facility, no oxygen tank or tubing had been provided. Record review showed the resident had diagnoses including COPD, a respiratory disorder, and diabetes mellitus, and the MDS indicated cognitive impairment and a need for substantial/maximal assistance with ADLs.

Review of the physician’s orders dated 1/9/2026 showed an order for oxygen at 3 L/min every shift related to COPD, but the order did not specify whether oxygen should be administered continuously or as needed. RN 1 acknowledged that the order lacked clarification on frequency and stated it was important to clarify the order with the physician and that an oxygen concentrator should have been available in the resident’s room for immediate use until clarification was obtained. The DON confirmed that the resident had a physician’s order for oxygen and that it was essential to follow physician orders, noting the resident could be at risk of respiratory distress if oxygen was not available for immediate use. Facility policies on oxygen administration and physician orders for respiratory modalities required provision of oxygen support when indicated and that all physician orders include modality, dosage, frequency, duration, and treatment diagnosis, which was not followed in this case.