Failure to Follow Ordered Oxygen Flow Rate for Resident on O2 Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for one resident receiving oxygen therapy. The resident, who had multiple diagnoses including diabetes and chronic obstructive pulmonary disease, had a physician’s order dated 2/12/26 for oxygen at 2 L/min via nasal cannula continuously, with instructions to maintain oxygen saturation at or above 88% and to check oxygen saturation every shift. On 2/23/26 at 11:22 AM, the resident was observed asleep in bed with an oxygen concentrator set at 4 L/min and the nasal cannula in place. On 2/24/26 at 10:20 AM, the resident’s oxygen concentrator was again observed set at 4 L/min in the presence of an RN, who stated the concentrator should not have been at 4 L/min and adjusted it back to 2 L/min. Later that day, the Regional Support Nurse acknowledged that someone should have identified the increased oxygen flow rate but had not. This failure to follow the physician’s ordered oxygen flow rate created the potential for residents to experience increased fatigue.
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