F0695

D

Failure to Provide Ordered Oxygen Therapy and Maintain Oxygen Equipment

Lowell, Indiana Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide proper respiratory care and oxygen administration for three residents with orders for oxygen therapy. One resident with COPD was observed multiple times in bed using oxygen via nasal cannula from a concentrator set at 1.5 L/min, with a humidity bottle attached that was dated several weeks earlier than allowed by facility policy, which required humidity bottles to be changed every seven days. This resident’s physician orders included changing oxygen tubing and humidity once a day on Sunday and allowing the resident, who was cognitively intact, to apply oxygen at 2 L/min via nasal cannula when feeling short of breath. Despite these orders and the policy, the humidity bottle remained outdated on repeated observations, and the ADON reported having no further information.

Another resident with COPD and respiratory failure, care planned as being at risk for impaired gas exchange and requiring oxygen therapy, was observed with inconsistent oxygen use and handling. On one occasion, the resident’s nasal cannula was seen lying on the floor while still connected to an oxygen concentrator; on other occasions, the resident wore a nasal cannula connected to either a portable concentrator set at 3 L/min or a concentrator set at 1.5 L/min, despite a physician order for oxygen at 2 L/min via nasal cannula every shift. A third resident with COPD and asthma, assessed as severely cognitively impaired and requiring oxygen therapy, had a physician order for oxygen at 2 L/min via nasal cannula every shift but was observed with oxygen in use on one day and then without oxygen on three subsequent days. In all three cases, the facility did not ensure that oxygen therapy and related equipment were managed in accordance with physician orders and the facility’s oxygen concentrator policy.