F0658

D

Oxygen Therapy Provided Without Physician Order or Care Plan

Pacific Grove, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that care and services were provided in accordance with professional standards of practice when a resident received oxygen therapy without a physician’s order and without an oxygen care plan. The resident was admitted with diagnoses including COPD with acute exacerbation and acute respiratory failure with hypoxia. Review of the resident’s Weights and Vital Summary for oxygen saturation from 1/12/26 to 1/14/26 indicated the resident was on oxygen via nasal cannula during that period. A CNA reported that the resident had been using oxygen via nasal cannula since the first day of stay.

During an interview and concurrent record review, the DON stated the resident was on continuous oxygen therapy at 2 LPM during the stay. When reviewing the resident’s care plan and physician order summary with active orders as of 1/14/26, the DON confirmed there was no care plan for oxygen use and no physician order in place. The facility’s policy on Oxygen Therapy required that oxygen be administered by a licensed nurse as ordered by the physician, and the facility’s MDS Baseline Care Planning policy required inclusion of any services and treatments to be administered by the SNF and its personnel. These policies were not followed in the provision of oxygen therapy to this resident.