Failure to Follow Baseline Care Plan for Oxygen Administration
Penalty
Summary
Facility staff failed to implement the baseline care plan for a resident requiring oxygen therapy. The resident had a physician’s order dated 1/30/26 for oxygen at two liters per minute for chronic obstructive pulmonary disease and a baseline care plan dated 2/2/26 documenting altered respiratory status, including wheezing, shortness of breath, and obstructive sleep apnea, with instructions to administer oxygen as needed per physician order. On 2/4/26 at 11:30 a.m., the resident was observed in bed receiving oxygen at a rate between three and four liters per minute, as indicated by the position of the ball in the oxygen concentrator flow meter between the three-liter and four-liter lines. Later the same day at 2:14 p.m., the resident was again observed in bed receiving oxygen at a rate between two and three liters per minute, with the ball in the flow meter between the two-liter and three-liter lines. During both observations, the oxygen concentrator was not within the resident’s reach. In an interview at 3:02 p.m., an LPN stated that care plans provide information so staff can meet residents’ needs, that nurses have access to residents’ care plans, and that nurses should check physician orders to ensure the correct oxygen amount is administered by verifying at eye level that the middle of the ball runs through the ordered liter line on the flow meter. The facility’s policy on care plans stated that a baseline care plan must be developed within 48 hours of admission to ensure residents’ needs are met appropriately until the comprehensive care plan is completed.
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