Failure to Implement Oxygen Orders and Care Plan for Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered comprehensive care plans for two residents in accordance with physician orders and assessed risks. For one resident with COPD, acute respiratory failure with hypoxia, anxiety disorder, type 2 diabetes mellitus, heart failure, and other conditions, the care plan dated 10/13/2025 identified altered respiratory status and directed staff to administer oxygen via nasal cannula as ordered by the physician and to monitor oxygen saturations. The physician order dated 1/29/2026 specified oxygen at 3 liters per minute via nasal cannula, continuous. However, on multiple observations over several days, the resident was noted to be receiving oxygen at between 4.5 and 5 liters per minute. An LPN confirmed the concentrator was set between 4.5 and 5 liters per minute, acknowledged that the order was for 3 liters per minute continuous, and stated she had not checked the flow rate or oxygen saturation that morning. The Director of Health Services also confirmed the incorrect flow rate and stated that nurses should ensure the correct liter flow is set and check oxygen flow rates throughout their shifts. The MDS Coordinator confirmed the care plan was for oxygen as ordered and that staff should follow the care plan and physician orders. The second deficiency concerns the facility’s failure to care plan for an assessed elopement risk for another resident. This resident was admitted with diagnoses including a non-displaced fracture of zone 1 sacrum and Alzheimer’s disease. The admission MDS showed that a BIMS assessment was not performed because the resident was rarely or never understood. An Elopement Assessment dated 1/17/2026 documented a score of 17, indicating a high risk for elopement. Despite this assessment, review of the resident’s care plan revised 2/4/2026 revealed no documented care plan problem addressing elopement risk. The Administrator stated that all residents were assessed for elopement risk as part of an elopement prevention improvement plan and confirmed that all residents identified as at risk for elopement should have a care plan problem for elopement. The MDS Nurse likewise confirmed that all residents identified as a risk for elopement should have a care plan for elopement.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.