F0684

D

Failure to Monitor and Administer PRN Oxygen for Resident With COPD and Respiratory History

Kansas City, Missouri Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer oxygen as ordered and to assess and monitor oxygen saturation levels and respiratory status for a resident with significant pulmonary diagnoses. The resident was readmitted with COPD, acute respiratory failure with hypoxia, and pneumonia, and had a care plan identifying potential for decline in respiratory status related to COPD exacerbations. The care plan interventions included administering medications and inhalers as ordered, monitoring for effectiveness and side effects, and monitoring and documenting changes such as increased restlessness, anxiety, air hunger, and signs and symptoms of respiratory distress to be reported to the physician. A physician’s progress note directed staff to monitor for recurrent respiratory symptoms, monitor oxygen saturation and respiratory rate, and assess the need for supplemental oxygen if clinically indicated.

The resident had an active physician order for supplemental oxygen at 2 L/min via nasal cannula as needed for oxygen saturation less than 90% and/or wheezing and shortness of air. However, the Medication Administration Record for the entire month showed no documentation of oxygen administration and no oxygen saturation assessments; all opportunities for oxygen administration and oxygen saturation assessments were blank. The facility’s own oxygen administration and vital signs policies required that oxygen be administered under physician orders, that staff document initial and ongoing assessments and responses to oxygen therapy, and that oxygen saturation be assessed for residents requiring oxygen at intervals specified by the physician. The vital signs policy also identified oxygen saturation as a vital sign, with an acceptable range above 90%, and required vital signs when a resident’s general condition changed or when nonspecific symptoms of physical distress were reported.

Interviews and observations further demonstrated that the resident’s respiratory needs and orders were not being implemented or monitored as required. The resident, who was cognitively intact, reported having pneumonia three times since admission, having oxygen ordered by the physician, experiencing shortness of air at night, and that staff did not check oxygen saturation levels. An oxygen saturation summary showed the resident’s oxygen saturation was assessed on one date in early September and not again until early March, indicating a long gap in monitoring. During observation, the resident stated they were not being administered oxygen, and there was no oxygen concentrator or portable oxygen tank in the room, despite the as-needed oxygen order and reported shortness of air.

Staff interviews revealed inconsistent practices and lack of awareness of the resident’s respiratory orders and monitoring needs. An RN stated it was standard practice to obtain vitals once per month, acknowledged not always documenting vitals in the EMR, had not assessed the resident’s oxygen saturation level, did not know when it was last assessed, did not know if the resident had an oxygen concentrator, and was unaware of the resident’s respiratory assessment and monitoring orders, despite knowing the resident had COPD and recent pneumonia. A CMT reported the resident complained of shortness of air and that this was reported to the RN, but the CMT did not assess oxygen saturation and stated CMTs had no place to document oxygen saturation in the EMR and were not aware of the resident’s respiratory and oxygen orders because those appeared only on the nurse’s side of the EMR. CNAs reported that nurses or CMTs were responsible for vitals, that they did not know how to access care plans or resident-specific oxygen and monitoring orders, and that they did not monitor oxygen saturation levels. An LPN described a practice of checking oxygen saturation and administering oxygen if saturation was below 90%, but this was not reflected in the resident’s documentation. The Administrator/DON confirmed expectations that vitals be obtained monthly, that physician orders be followed, that respiratory assessments including vitals be completed when residents report shortness of air, and that residents with COPD have vitals and oxygen saturation monitored as needed, expectations that were not met in this resident’s case.