F0695

E

Failure to Follow Oxygen Therapy Orders and Document Respiratory Assessments

Socorro, New Mexico Survey Completed on 12-16-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow professional standards of practice for oxygen therapy for three residents with chronic respiratory conditions. One resident with chronic respiratory failure with hypoxia and simple chronic bronchitis had a physician’s order for continuous oxygen via nasal cannula at 1–2 LPM. Surveyors observed this resident sitting in a wheelchair without a nasal cannula, with the oxygen concentrator turned off, and the resident stated he only wore oxygen at night and as needed during the day. On another observation in the dining area, the resident again was not wearing a nasal cannula and did not have a portable oxygen concentrator. An LPN and the ADON both stated that the resident used oxygen at night and as needed during the day, despite the physician’s order for continuous oxygen, and the ADON stated staff were expected to ensure residents wore oxygen as ordered and notify the provider if a change in condition indicated the order might need to be changed.

A second resident, admitted with COPD, chronic respiratory failure with hypoxia, a solitary pulmonary nodule, and dependence on supplemental oxygen, had conflicting oxygen orders between hospice and the facility. Hospice admission orders directed oxygen via nasal cannula at 8–10 LPM, while the physician’s order in the facility record specified 6–8 LPM for COPD. Progress notes documented that staff found the resident’s oxygen concentrator at 10 LPM and educated him that it should be at 8–10 LPM, but there was no documentation that a provider was notified or that a full respiratory assessment was completed. Subsequent notes showed the concentrator was decreased to 15 LPM (outside the 6–8 LPM order, with no documentation of the prior setting), and that hospice was notified, but again there was no documented respiratory assessment beyond oxygen saturation. Another entry described an episode of shortness of breath with oxygen saturation dropping to 42%, treatment with ordered albuterol and anxiety medications, and oxygen increased to 14 LPM, outside the ordered range, without documentation of a respiratory assessment or provider notification. An LPN later stated she was not aware of the hospice order for 8–10 LPM, that the resident usually had oxygen at 10 LPM, and that although she assessed lung sounds, she never documented a respiratory assessment. The ADON confirmed staff were expected to assess respiratory status at least every shift, ensure facility orders matched hospice admitting orders, and notify the provider if higher oxygen concentrations were needed.

A third resident with chronic respiratory failure had admission orders for continuous oxygen starting at 2 LPM and increasing to keep oxygen saturation greater than 90%. The physician’s order in the record, however, was entered as an order to increase oxygen requirement by 2 LPM to keep oxygen saturation greater than 90%, which did not match the admission order to start at 2 LPM. During one observation, the resident was in bed wearing a nasal cannula with the concentrator set at 3 LPM. On a later observation, the resident was in bed with the nasal cannula lying on the oxygen concentrator, the concentrator turned off, and the resident stated staff had put her to bed after lunch and forgot to put her oxygen on. An LPN confirmed the resident should always wear her nasal cannula, that the concentrator was usually set at 3 LPM, that the order was to start at 2 LPM and increase to keep saturation above 90%, and that at the time of observation the resident was not wearing the nasal cannula and should have been. A regional clinical nurse later confirmed the oxygen order had been entered incorrectly and reiterated that residents should wear oxygen as ordered unless they refuse, with physician notification and documentation required if they refuse.

The report states that if the facility is not assessing respiratory status and following orders for oxygen use, the resident may be low on oxygen, which could potentially cause health concerns such as shortness of breath, confusion, rapid heart rate, fatigue, and cyanosis.