Failure to Obtain and Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and follow physician orders for oxygen therapy and to adhere to its own oxygen administration policy for two residents. Facility policy required that oxygen be administered only under a physician’s order, at the ordered rate and route, and that oxygen tubing and cannulas be changed weekly and as needed. For one resident with COPD, interstitial pulmonary disease, atrial fibrillation, and dependence on supplemental oxygen, the physician’s order specified continuous oxygen at 2 L/min via nasal cannula. However, observations on multiple occasions showed the oxygen concentrator set at 3.5 L/min, and the tubing/cannula was not dated. The medical record for this resident contained no physician order for oxygen tubing/cannula changes in December 2025 and January 2026, and the MAR/TAR for those months showed no documentation that the tubing/cannula had been changed, despite ongoing daily oxygen administration. For a second resident with dementia, heart disease, heart failure, hyperlipidemia, and hypertension, multiple entries on the Weights and Vitals Summary and skilled nursing notes documented the use of oxygen via nasal cannula over several months, and nursing documentation referenced oxygen saturations obtained while the resident was on oxygen. Despite this, there was no physician order for oxygen therapy in the physician orders for September 2025 or December 2025, and the resident’s care plan did not include oxygen therapy. Observations over two days showed the resident receiving oxygen via nasal cannula at settings between 2 and 2.5 L/min, while nursing staff verbally indicated the order was for 2 L/min and that the resident had been on oxygen since approximately July. A physician order for oxygen at 2 L/min PRN was not obtained until January 7, 2026, after which the concentrator was still observed set between 2 and 2.5 L/min. In interviews, the DON confirmed that oxygen should not be administered without an order, that residents on oxygen should have orders for tubing/cannula changes, and that oxygen should be administered at the prescribed rate.
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