F0695

E

Failure to Maintain Accurate Respiratory Therapy Orders and Documentation

Albuquerque, New Mexico Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards for multiple residents using supplemental oxygen and a CPAP device. For one resident with spastic quadriplegic cerebral palsy, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and epilepsy, the medical order dated 03/21/23 directed oxygen at “one to six liters per minute” via nasal cannula continuously, without specifying an exact flow rate. This resident was observed in bed on oxygen via nasal cannula connected to a concentrator, and the Interim DON confirmed the order did not specify the exact amount of oxygen needed. Another resident with COPD, iron deficiency anemia, chest pain, muscle weakness, and peripheral vascular disease was observed wearing a nasal cannula attached to an oxygen concentrator, with a current order dated 03/29/25 for “three to four liters of oxygen per minute” via nasal cannula, again without a precise flow rate; the DON confirmed the order did not specify the exact amount of oxygen this resident should receive.

A third resident with pneumonia, COPD, pulmonary hypertension due to lung disease and hypoxia, chronic kidney disease stage 2, and iron deficiency anemia was observed wearing a nasal cannula connected to an oxygen concentrator, but record review of the physician record showed no orders for oxygen use or oxygen device care. The care plan dated 03/25/25 noted the resident was at risk for respiratory complications related to COPD and stated “O2 as ordered,” yet there was no corresponding physician order. The DON confirmed that this resident did not have an order for oxygen use and should have had one. Another resident with COPD with exacerbation, vascular dementia, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and pneumonia had a CPAP machine at bedside and reported using it every night, with hospital discharge documentation ordering CPAP use. However, the MDS dated 12/02/25 indicated the resident did not use a non-invasive ventilator, the care plan dated 03/29/25 did not include CPAP use, and there was no current physician order for CPAP; the DON confirmed the resident uses CPAP and that the order, MDS, and care plan were not accurate to the resident’s needs.

A fifth resident with dementia, mild intermittent asthma, permanent atrial fibrillation, obstructive sleep apnea, and a cardiac pacemaker was observed wearing a nasal cannula connected to a portable oxygen concentrator attached to the wheelchair. This resident’s medical orders dated 12/31/25 included one order to wear oxygen at “one to five liters” via nasal cannula continuously and another order to have oxygen at “one to five liters” via nasal cannula as needed. The Interim DON confirmed that these orders did not specify the exact amount of oxygen required and did not clarify whether the resident needed continuous or PRN oxygen. Across these residents, surveyors identified missing or incomplete physician orders, lack of specific oxygen flow rates, and inaccurate or incomplete documentation in the care plan and MDS related to respiratory therapies.