Failure to Provide Ordered Oxygen and Safe PAP Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services as ordered for three residents requiring continuous or prescribed oxygen and PAP therapy. Facility policy required BiPAP/CPAP therapy to be provided in accordance with physician orders and professional standards, and the PAP user manual specified that when oxygen is used with the device, a specific pressure valve must be installed between the device and oxygen source, and that the device must be turned on before oxygen and off after oxygen is turned off to prevent oxygen accumulation and fire risk. For one resident with COPD, depression, and cardiomegaly, a physician order dated 3/9/26 required oxygen at 3 LPM continuously via nasal cannula, yet surveyors observed on three separate dates and times that the resident was in her room without the nasal cannula in place. The CNO confirmed that this resident should have had her oxygen on continuously as ordered and had not. Another resident with PTSD and joint replacement aftercare had CPAP orders specifying CPAP with 2 L/min oxygen at bedtime and a separate physician order for oxygen at 3 L via nasal cannula every shift for obstructive sleep apnea. On observation with an RN present, the resident’s oxygen concentrator was on and bleeding 3.5 LPM of oxygen into the CPAP device while the CPAP device itself was turned off, and no required Respironics pressure valve was installed in the PAP circuit. Additional observations on two mornings showed the resident was not using ordered oxygen, and an RN stated the resident does not use oxygen during the day and questioned whether there was an order for daytime use. A third resident with acute osteomyelitis of the right ankle and foot and a lumbar vertebra fracture had a physician order and care plan for 2 LPM oxygen continuously via nasal cannula to maintain SpO2 at or above 90%, yet was observed not using oxygen, and medical record entries documented SpO2 readings of 88% on two dates while on room air only. The CNO stated staff should have ensured ordered oxygen use for the two residents, acknowledged oxygen should not bleed into a PAP device when not in use, and reported being unaware of the requirement for the Respironics pressure valve or whether any PAP devices in the facility had it.
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