F0695

E

Failure to Maintain Oxygen Equipment and Administer Ordered Oxygen Therapy

El Paso, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide safe and appropriate respiratory care, including proper oxygen administration and equipment maintenance, for multiple residents requiring continuous oxygen therapy. Surveyors identified that the facility did not have a system or contract in place to ensure oxygen concentrators were serviced and maintained to deliver prescribed flow rates. Several concentrators in storage areas and in use lacked QA or maintenance stickers, and one concentrator stored under a hand sink was known by the DON to be non‑functional but was neither labeled as out of order nor stored separately. The ADON reported she did not know if there was a contract with an oxygen supplier for maintenance, and the Administrator, DON, and ADON confirmed there was no such contract at the time of the survey.

One resident with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, COPD, and recent ICU hospitalization was admitted with orders for continuous oxygen at 2–6 L/min via nasal cannula and had a history of hypoxia and altered mental status. Facility documentation showed that upon arrival his oxygen saturation was low (around 73–80%) while on oxygen via nasal cannula, and staff reported he was placed on 6 L/min. A family member reported to staff and later to the Administrator that the oxygen equipment was not delivering enough oxygen, and an SBAR noted worsening hypoxia with oxygen saturation at 74% on nasal cannula and a family request to send the resident out because he was not receiving enough oxygen through the concentrator. EMS documentation indicated that nursing home staff reported the resident had been discharged from the hospital for hypoxia and that his oxygen saturation was 75% on 6 L/min via nasal cannula at the facility, prompting EMS activation.

Another resident with COPD and an order for continuous oxygen at 1 L/min via nasal cannula was observed sitting at the nurse’s station without her oxygen in place, despite an order and care plan specifying continuous oxygen. The LVN at the nurse’s station stated she had not noticed the missing cannula until the surveyor pointed it out, and only then checked the resident’s oxygen saturation and returned her to her room to reapply the cannula and set the concentrator. A further resident with pneumonia, dependence on supplemental oxygen, acute and chronic respiratory failure with hypoxia, and Parkinson’s disease had an order for continuous oxygen at 2–3 L/min via nasal cannula, but was observed with the concentrator set at 1.5 L/min. The DON confirmed at the bedside that the concentrator was set below the ordered 2 L/min and stated the resident should be on 2 L/min as ordered.

A fourth resident with asthma, pulmonary embolism with acute cor pulmonale, and shortness of breath had an order for continuous oxygen at 2–4 L/min via nasal cannula. During observation, the ADON demonstrated that the oxygen concentrator in use for this resident had a maintenance service tag dated 10/04/2019. The ADON stated the resident had just been changed to a different concentrator because her oxygen was changed to 5 L/min, and it was observed that the regulator was set at 5 L/min via nasal cannula. The facility’s written policy on oxygen therapy addressed reviewing physician orders and emergency use of oxygen for low saturations but did not include any policy or procedure for maintenance of oxygen concentrators, contributing to the lack of a structured system to ensure concentrators were functioning properly and delivering ordered flow rates.

Interviews with the Medical Director confirmed awareness of standing orders for oxygen at 2–6 L/min via nasal cannula with shift oxygen saturation monitoring and that nurses could adjust liters within that range, but he was not aware that the facility lacked a system for vendor maintenance of concentrators. A vendor representative later described the type of maintenance required for concentrators, including filter care and oxygen concentration testing, underscoring that such maintenance had not been in place at the time of the identified events. Overall, the deficiency centers on the facility’s failure to maintain and monitor oxygen equipment and to consistently administer oxygen as ordered, as evidenced by unmaintained concentrators, lack of labeling of non‑functional equipment, and residents not receiving oxygen continuously or at the prescribed flow rates.