F0695

D

Failure to Safely Manage and Provide Oxygen Therapy

Findlay, Ohio Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The facility failed to ensure safe storage and dating of respiratory supplies and timely, sufficient provision of supplemental oxygen for two residents. For one resident with chronic obstructive pulmonary disease and chronic respiratory failure, a quarterly MDS showed intact cognition and a need for oxygen therapy, and the care plan identified potential complications related to respiratory disease and oxygen use. During observation, the resident’s oxygen concentrator was running at two liters with undated tubing attached to a nasal cannula lying on the floor in front of the concentrator, and additional undated tubing with an oxygen mask was also lying on the floor. An LPN confirmed that the undated tubing, nasal cannula, and oxygen mask were on the floor.

For another resident with chronic respiratory failure with hypoxia, stage five chronic kidney disease, chronic heart failure, and obstructive sleep apnea, the quarterly MDS indicated intact cognition, dependence for transfers and mobility, need for assistance with ADLs, cardiorespiratory diagnoses, and use of oxygen therapy. Physician orders required continuous oxygen at two liters per minute via nasal cannula. Observation found the resident in the dining room wearing an undated nasal cannula connected to a portable oxygen tank set at two liters per minute, with both gauges on the tank indicating it was empty. The resident reported increased shortness of breath since awakening that morning and continued shortness of breath at the time of interview. A CNA confirmed the nasal cannula was not dated and the portable tank gauges showed the tank was empty. Facility policies required monthly changes of oxygen cannula and tubing, storage in a plastic bag when not in use, and dating of oxygen tubing, which were not followed in these instances.