F0695

D

Failure to Provide and Document Ordered Oxygen Therapy in Accordance With Professional Standards

Cambridge, Maryland Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document respiratory services, specifically oxygen therapy, in accordance with professional standards of practice for one resident. The resident was admitted from an acute care facility with diagnoses including seizures, traumatic brain injury, and chronic pain with a spinal cord stimulator, and the admission MDS and nursing admission assessment documented that the resident was admitted with oxygen and received oxygen while in the facility. However, a review of physician orders for October 2025 through January 2026 did not show any physician order for oxygen, and there were no entries on the MAR or TAR indicating that oxygen was administered during those months. Vital sign documentation showed oxygen use on three dates in early November, but there were no nursing assessments from November 1 through November 7 documenting oxygen usage or respiratory status.

Further review of skilled nursing assessments throughout November and December showed multiple assessments that did not mention oxygen use, with only a few dates documenting that the resident was on oxygen, and without specifying the number of liters, tubing change schedule, or whether humidification was required. The resident’s care plan did not include any plan for oxygen use. During interviews, the resident reported being on oxygen at admission but no longer needing it, while an RN stated the resident was non-compliant and currently refusing oxygen, acknowledged that a physician order was required, and was unable to locate such an order or any documentation of oxygen use in the medical record. The DON and VP of Operations were informed of these findings, and the Medical Director was informed that the NP’s comprehensive assessments did not address the resident’s oxygen usage.