F0658

E

Failure to Follow Oxygen Orders and Medication Administration Standards

Lake City, Iowa Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

Surveyors identified multiple failures to follow professional standards of quality related to oxygen administration, medication administration, infection control, and medication storage. One resident with severe cognitive impairment and chronic obstructive pulmonary disease had a physician order and care plan for oxygen at 1.5 L/min via nasal cannula. However, clinical records, including weights and vitals and progress notes, repeatedly documented the resident receiving oxygen at 2 L/min on several occasions. During observation, the resident was seen in bed on 1.5 L/min via concentrator, but later in the dining room on 2 L/min via a portable tank, inconsistent with the ordered 1.5 L/min. Facility leadership could not explain why oxygen was documented or set at 2 L/min and acknowledged that an agency CNA had turned the oxygen up to 2 L/min.

Surveyors also observed failures in medication administration and infection control practices. A cognitively intact resident with pain was given ibuprofen 200 mg by a CMA, who walked away before confirming the resident swallowed the medication. Another cognitively intact resident on diuretic therapy was given Coenzyme Q10 and Lasix 40 mg by the same CMA, who again left the room before observing ingestion. For a third cognitively intact resident with atrial fibrillation, the CMA prepared PRN Tylenol by taking two round white tablets from a clear plastic cup stored in the top drawer of the med cart, handling the tablets with bare fingers and not from the original container. The DON, ADON, and Administrator confirmed that staff should observe residents swallowing medications, should not touch medications with bare hands, and should store medications in their original containers until administration, as required by the facility’s medication administration policy.