Failure to Follow Oxygen Therapy Orders for Two Residents
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for two residents. One resident with COPD and depression had a physician order for continuous oxygen at 1.5 L/min via nasal cannula starting 11/6/25, but was observed on multiple occasions receiving oxygen at 2 L/min via nasal cannula in both the dining room and her room. Both the bedside oxygen concentrator and the portable concentrator on her walker were labeled and set to deliver 2 L/min, and an RN confirmed that the oxygen rate should have been 1.5 L/min as ordered and had not been. Another resident with diagnoses including orthopedic aftercare, Sjogren's disease, and diabetes had a physician order for weekly oxygen tubing changes and humidifier bottle changes every Sunday on the night shift, starting 12/21/25. Surveyors observed on three separate days that this resident’s oxygen humidifier bottle was still dated 12/28/25, indicating it had not been changed according to the order. The DON stated that the humidifier should have been changed on the most recent Sunday and had not been.
