Failure to Follow Physician-Ordered Oxygen Flow Rate
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care related to failure to regulate and monitor oxygen liter flow rates according to physician orders for one resident. Facility policy titled "Oxygen Administration" revised 8/2/2023 states that oxygen is to be provided safely and accurately and that staff are to regulate liter flow to the ordered/desired flow rate. The resident involved had a recent Quarterly MDS dated 1/20/2026 showing a BIMS score of 15, indicating little to no cognitive impairment, and active diagnoses including COPD, acute respiratory failure with hypoxia, anxiety disorder, type 2 diabetes mellitus, heart failure, and functional dyspepsia. The resident’s care plan, dated 10/13/2025, documented altered respiratory status/difficulty breathing related to COPD, with interventions including administering oxygen via nasal cannula as ordered by the physician and monitoring oxygen saturations as ordered. Physician orders for this resident, dated 1/29/2026, specified oxygen at 3 LPM via nasal cannula, continuous. However, multiple observations showed the oxygen concentrator set above the ordered rate: on 2/3/2026 at 12:55 PM the flow rate was between 4.5 and 5 LPM; on 2/4/2026 at 12:10 PM it was set at 5 LPM; and on 2/5/2026 at 9:50 AM it was again between 4.5 and 5 LPM while the resident was wearing oxygen. During an observation and interview on 2/5/2026 at 10:10 AM, an LPN confirmed the concentrator was set between 4.5 and 5 LPM and stated that staff should ensure residents receive the correct oxygen liters per minute, acknowledging that this resident’s flow rate should have been 3 LPM continuous. The LPN reported she had not checked the oxygen flow rate or oxygen saturation that morning and should have done so. The Director of Health Services later confirmed that nurses are expected to ensure the correct liter flow per physician orders and to check oxygen flow rates throughout their shifts, and confirmed that the resident’s oxygen flow rate had been between 4.5 and 5 LPM.
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