Failure to Follow Ordered Oxygen Liter Flow Settings
Penalty
Summary
Surveyors found that the facility failed to provide respiratory services as ordered by the physician for one resident with chronic respiratory failure with hypoxia and a history of stroke. The facility’s Oxygen Administration policy required oxygen orders to include a specific liter flow, and the physician’s order for this resident, dated 11/12/23, specified oxygen at 1 liter per minute via nasal cannula continuously. The resident’s care plan directed staff to provide supplemental oxygen per the medical order, and the MAR documented that oxygen was administered at 1 liter per minute on specified dates and shifts. However, on 3/16/26 at 1:29 PM, the resident was observed in bed with a nasal cannula in place while the oxygen concentrator was set at 2 liters per minute, and the resident stated she was on 2 liters per minute of oxygen. On 3/17/26 at 9:04 AM, the oxygen concentrator was again observed, this time set at 2.5 liters per minute. At 9:08 AM, an RN acknowledged that the oxygen should have been set at 1 liter per minute and had not been. On 3/18/26 at 9:28 AM, the DON stated that the resident’s oxygen concentrator liter flow setting should be checked often or at least every shift by nursing staff and that this had not been done. The report stated this failure created the potential for residents to experience increased fatigue and low oxygen levels.
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