F0695

D

Failure to Administer Oxygen at Prescribed Flow Rate

Beaufort, North Carolina Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer oxygen at the physician-prescribed rate for a resident with significant respiratory and cardiac conditions, including chronic respiratory failure with hypoxia, COPD with acute exacerbation, chronic diastolic CHF, partial lung absence, and dependence on supplemental oxygen. The physician’s order, written on 1/8/26, specified oxygen at 3 LPM via nasal cannula, and the care plan initiated on 1/9/26 identified the resident as requiring continuous oxygen use with an intervention of oxygen as ordered. On multiple observations, the resident was noted to be receiving oxygen via nasal cannula from a concentrator set at 2 LPM instead of the ordered 3 LPM. During an interview, the resident, who was cognitively intact, did not know what the oxygen flow rate was supposed to be.

Nursing staff interviews confirmed that the oxygen flow rate was not consistently checked against the physician’s orders each shift as expected. Nurse #2, who cared for the resident on 1/20/26, acknowledged knowing the order was for 3 LPM but stated she might not have checked the concentrator settings due to having a lot going on that day. On 1/21/26, Nurse #1, who was assigned to the resident that day, stated that nurses were supposed to verify oxygen settings once a shift but admitted she had not done so when she was in the room earlier that morning and that it was her first time working on that hall. When she reviewed the physician’s orders, she confirmed the concentrator should have been set at 3 LPM, while observations showed it remained at 2 LPM until it was adjusted later. The DON and Administrator both stated their expectation that nursing staff follow MD orders and facility policy regarding oxygen therapy and check concentrator settings every shift.