F0695

D

Failure to Provide Ordered Continuous Oxygen Therapy

Amarillo, Texas Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered continuous oxygen therapy to a resident with significant cardiopulmonary conditions. The resident was an elderly female admitted with diagnoses including pulmonary embolism, COPD, right lung cancer, pulmonary hypertension, acute on chronic diastolic heart failure, and acute and chronic respiratory failure with hypoxia. Her quarterly MDS showed severely impaired cognition (BIMS score of 6) and documented that she was receiving oxygen therapy while a resident. The comprehensive care plan included multiple focus areas (oxygen therapy, COPD, chronic pain, and congestive heart failure) with interventions directing staff to provide oxygen therapy as ordered by the physician.

Record review showed a physician’s order dated 11/04/25 for oxygen at 2–3 L/min via nasal cannula (NC), to be given continuously. However, oxygen saturation documentation on 11/18/25 at 5:00 PM and 8:15 PM, completed by LVN B, showed the resident’s oxygen saturation was 90% on room air at both times, indicating she was not receiving oxygen therapy when her oxygen level was checked. Progress notes for that date, including a note by LVN B at 5:00 PM after the resident was found on the floor, documented an oxygen saturation of 90% on room air but did not mention any resistance to oxygen use or removal of the NC by the resident.

Interviews and photographic evidence further supported that the resident was not receiving continuous oxygen as ordered. A family member reported visiting the resident for about an hour and a half during the evening meal and stated the resident did not have oxygen on at any time during the visit while seated near the nurses’ station. Another family member, who participated via FaceTime, provided 15 time-stamped photographs from that visit showing the resident without oxygen between 5:31 PM and 6:14 PM. Facility staff, including the ADON, RN C, OM, LVN A, and the DON, acknowledged in interviews that residents with continuous oxygen orders should not have it removed, though some stated residents may refuse and that staff should chart refusals and monitor oxygen saturations. Facility policies on oxygen therapy and medication administration required that oxygen, as a prescribed drug, be administered as ordered and that refusals be documented on the MAR or eMAR, which was not reflected in the records for this resident on the date in question.