F0695

E

Failure to Titrate and Document Oxygen Therapy per Orders and Professional Standards

Colorado Springs, Colorado Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide respiratory care, specifically oxygen therapy, in accordance with professional standards and physician orders for multiple residents. For several residents with respiratory diagnoses, including COPD, acute respiratory failure with hypoxia, and chronic respiratory failure with hypoxia, oxygen was administered at higher flow rates than their documented baseline or hospital discharge levels, without documented clinical need or titration based on SpO2 readings. Oxygen was treated as a standing range order (1–5 LPM with a goal SpO2 ≥ 88%), but staff did not consistently titrate down when saturations were well above the target range, and there was no documentation supporting the need for increased flow.

One resident with acute respiratory failure, asthma, and obstructive sleep apnea was discharged from the hospital and admitted on 1 LPM of oxygen, with initial SpO2 readings of 92–95%. However, the MAR showed the resident on 3 LPM starting the day after admission, and surveyors observed the resident repeatedly on 4 LPM. There was no documentation that the resident’s oxygen saturation had dropped below the ordered threshold to justify increasing the flow. The resident reported not understanding how staff determined his oxygen needs and did not know his flow rate. An agency RN caring for this resident stated she was not informed of his baseline oxygen needs, did not receive updated report sheets, and believed that because the order allowed 1–5 LPM, she did not need to titrate down or notify the provider when the resident’s SpO2 was 97% on 4.5 LPM.

Another resident with interstitial pulmonary disease and chronic respiratory failure with hypoxia was observed on 4 LPM via nasal cannula, despite a hospital discharge summary indicating a baseline of 3 LPM. The resident confirmed her baseline was 3 LPM. The CPO contained the same 1–5 LPM titration order to maintain SpO2 ≥ 88%, and staff reported that a NP had reduced the oxygen because the saturation was good and baseline was 3 LPM, yet the resident was still observed on 4 LPM. For two additional residents with COPD and continuous oxygen orders of 1–5 LPM with titration to maintain SpO2 ≥ 88%, EMR review showed their oxygen saturations remained above 93% over extended periods, but there was no documentation that oxygen was titrated down or omitted when within range. One RN believed the resident was on 2.5 LPM when the resident was actually on 3.5 LPM, and an LPN acknowledged not knowing the exact liter flow for a resident on oxygen and not notifying providers when changing flow within the ordered range.

Across these cases, staff interviews revealed inconsistent understanding and implementation of oxygen titration. Multiple nurses and the DON acknowledged that oxygen is a medication requiring an order, but described relying on broad standing orders (1–5 LPM) and nursing judgment without routinely notifying providers when changing flow rates, as long as they stayed within the range. The DON stated that nurses were expected to document changes in oxygen flow in the vital signs log and did not need to notify providers unless the flow exceeded 5 LPM, while one NP stated that the standard protocol was for nursing staff to notify the provider of any change in oxygen titration and to wean residents off oxygen as soon as possible. Training records provided showed education on initiating oxygen and changing tubing, but did not include guidance on when to notify providers of changes in oxygenation or how to titrate oxygen appropriately within ordered parameters.