Failure to Follow Physician Order for Oxygen Administration
Penalty
Summary
Surveyors identified that the facility failed to follow its oxygen administration policy and the physician’s order for a hospice resident receiving oxygen therapy. On 11/18/25 at 10:15 AM, the resident was observed in bed with an oxygen concentrator at the bedside set at 3 L/min via nasal cannula. At 11:00 AM the same day, a nurse confirmed that the oxygen setting was 3 L/min and stated that the resident was on continuous oxygen at that rate. Record review showed a physician’s order, effective 9/5/25, for continuous oxygen at 1 L/min via nasal cannula. The resident is an adult male under hospice care with a diagnosis of COPD that began on 7/18/25. The DON stated that nurses are expected to follow physician orders for oxygen administration and to call the attending physician for an order if oxygen needs to be increased. The facility’s Oxygen Administration Policy, revised October 2010, requires verification of a physician’s order and review of the order or facility protocol for oxygen administration, which was not followed in this case. This deficient practice affected one resident out of three reviewed for oxygen administration in a total sample of 23 residents.
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