F0658

E

Oxygen Administered Without Physician Order

Rio Rancho, New Mexico Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

Facility staff administered oxygen to a resident without a physician’s order, failing to ensure services met professional standards of quality. The resident was admitted with chronic systolic congestive heart failure and chronic obstructive pulmonary disease. Nursing progress notes documented that the resident was provided oxygen via nasal cannula on three separate dates (01/11/26, 02/20/26, and 02/23/26). However, review of the electronic health record on 03/09/26 showed there were no past or present physician orders for oxygen use for this resident.

During observation of the resident’s room on 03/09/26, surveyors noted an oxygen concentrator with a nasal cannula attached and a portable oxygen tank available for use. In an interview, the resident stated he uses oxygen when he has difficulty breathing. The Unit Manager stated that all residents who need supplemental oxygen should have a physician’s order for PRN or continuous use and confirmed that this resident did not have such an order. The Administrator also stated her expectation that all residents requiring supplemental oxygen have a valid physician’s order and acknowledged that receiving oxygen without an order could result in the wrong treatment and pose a risk to resident safety and health.