Failure to Administer Ordered Oxygen Liter Flow and Accurate eMAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen as ordered by the physician for a resident with congestive heart failure, COPD, and chronic respiratory failure. The resident was admitted with these diagnoses and had a physician’s order dated 10/02/2025 for continuous oxygen at 3 liters per minute via nasal cannula for shortness of breath. The quarterly MDS indicated the resident was cognitively intact, received oxygen therapy, and used a non-invasive mechanical ventilator. On multiple observations on 02/16/2026, 02/17/2026, and 02/18/2026, the resident’s oxygen via nasal cannula connected to the bedside oxygen flowmeter was found set at 2 liters per minute instead of the ordered 3 liters per minute. During an interview, the resident stated that her oxygen was supposed to be set at 3 liters per minute and reported that when she was placed in her wheelchair, nursing staff sometimes set the oxygen at 2 liters instead of the prescribed 3 liters. She stated staff informed her of the oxygen setting and the amount remaining in the tank because the equipment was positioned behind her wheelchair. Review of the eMAR showed that Nurse #6 documented that the resident received oxygen at 3 liters per minute on 02/16/2026, 02/17/2026, and 02/18/2026 on first shift, and Nurse #7 documented that the resident received oxygen at 3 liters per minute on 02/17/2026 and 02/18/2026 on night shift, despite the observed setting of 2 liters per minute. Nurse assignment sheets confirmed that Nurse #6 and Nurse #7 were responsible for the resident’s care on the dates in question. In an interview, Nurse #6 acknowledged that the oxygen was set at 2 liters per minute and confirmed the physician’s order for 3 liters per minute continuously. She stated the resident had told her months earlier to set the oxygen at 2 liters based on home use and that the resident had been receiving 2 liters previously; she was unaware of the updated order for 3 liters per minute. Nurse #6 explained that the eMAR allowed her to document oxygen as administered by selecting yes or no and that she documented yes because she believed the resident was receiving 3 liters per minute. Nurse #7 similarly stated she documented oxygen as administered because she believed the resident was receiving 3 liters per minute. Unit Manager #1 stated that if oxygen was set at the wrong liter flow it was to be corrected immediately and that nursing staff should routinely check oxygen settings, but she had not previously noticed an incorrect setting for this resident. The NP stated that, due to the resident’s COPD, oxygen must be maintained at the prescribed liter flow, and the DON and Administrator both reported they were unaware that the resident’s oxygen was not being administered at the prescribed setting, while stating that staff were expected to follow physician orders.
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