Failure to Administer Oxygen at Prescribed Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen at the prescribed rate for a resident with significant cardiopulmonary conditions. The resident was readmitted with diagnoses including atrial fibrillation, congestive heart failure, and shortness of breath, and had a physician’s order dated 11/19/24 for continuous oxygen via nasal cannula at 2 liters per minute (L/min) to maintain oxygen saturation above 90%. This order was indefinite and was reflected in the resident’s care plan, which identified a risk for ineffective breathing pattern related to congestive heart failure and shortness of breath, with an intervention to administer oxygen as ordered. The Medication Administration Record (MAR) also contained the order for oxygen at 2 L/min via nasal cannula every day and night shift, with two 12-hour blocks per day for staff to confirm the flow rate. Record review of the January 2026 MAR showed that staff documented the oxygen flow rate as 2 L/min twice daily on multiple days, including 1/20/26, 1/21/26, and 1/22/26. Specifically, Nurse #3 documented that the oxygen was set at 2 L/min for the day shift on 1/20/26 and 1/21/26, and Nurse #1 documented that the oxygen was set at 2 L/min for the day shift on 1/22/26. However, during observations on 1/20/26 at 10:52 AM, 1/21/26 at 9:00 AM, and 1/22/26 at 10:07 AM, the resident was seen with a nasal cannula in place, and the oxygen concentrator regulator was set at 3 L/min when viewed horizontally at eye level. On 1/22/26, the 3 L/min setting was verified with Nurse #1 present. In interviews, Nurse #3 stated she followed what was listed on the MAR and would review it for medications or treatments but did not answer specific questions about the oxygen orders for this resident and was not available for follow-up. Nurse #1 acknowledged that the resident had a physician order for oxygen at 2 L/min via nasal cannula and stated he had checked the “yes” radio button in the MAR indicating the oxygen was set at 2 L/min, but he admitted he had not visually checked the flow rate earlier when administering morning medications and agreed the settings needed to be corrected. The Unit Manager, NP, ADON, DON, and Administrator each stated in interviews that nurses were expected to ensure oxygen was delivered at the provider-ordered rate, visually confirm the oxygen flow rate before documenting in the MAR, and contact the provider if any change in oxygen rate was needed. Despite these expectations, the oxygen regulator remained set at 3 L/min while staff documentation indicated 2 L/min, resulting in the failure to administer oxygen at the prescribed rate.
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