F0658

E

Failure to Follow Physician Orders for Oxygen Therapy and STAT Diagnostics

Albuquerque, New Mexico Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure oxygen therapy was administered according to physician orders for Resident #3. The resident had diagnoses including COPD, acute respiratory failure with hypoxia, and acute respiratory failure, with an order for continuous oxygen via nasal cannula at 5.5 LPM to maintain oxygen saturation above 90%. Observations on multiple days showed the portable oxygen device turned off and set at zero, later turned on but set at only 4 LPM, and the resident in bed without a nasal cannula while the concentrator was running at 4 LPM with no cannula attached. A subsequent observation found the portable oxygen device empty and unable to deliver oxygen, with oxygen saturation documented at 84–86% on room air. Staff interviews confirmed that the oxygen should have been on, set to the ordered flow rate, and that the resident required assistance with oxygen therapy. One CNA reported removing the nasal cannula, finding it on the floor, and not replacing it, leaving no nasal cannula readily available for the resident.

Resident #3’s care plan identified risks for respiratory complications, falls, and skin breakdown related to respiratory failure, and a change-in-condition note documented episodes of lethargy, mumbling speech, and oxygen saturations as low as 70–81% on 6 LPM of oxygen, with concern for acute exacerbation of congestive heart failure. Despite these documented respiratory issues and the facility’s oxygen concentrator policy outlining proper setup and use, the resident was repeatedly observed without appropriate oxygen delivery equipment in place or with devices not set to the prescribed flow rate. The DON confirmed that oxygen was not provided continuously via nasal cannula at 5.5 LPM as ordered and stated it was her expectation that oxygen be administered per physician orders.

The deficiency also involves the facility’s failure to follow physician orders for STAT laboratory tests and a STAT X-ray for Resident #17. This resident had diagnoses including a right femur fracture, DM2, cognitive communication loss, and right hip pain, and developed severe left knee pain with swelling and decreased range of motion. An after-hours provider ordered STAT CBC, CMP, CRP, and a STAT X-ray of the left knee. Physician orders documented these STAT tests and imaging for severe left knee pain. However, the resident’s daughter reported that when she arrived the next day, she was told the labs and X-ray had not been completed because the orders were not documented correctly. The DON confirmed that the STAT orders for labs and X-ray were not documented correctly, which led to a delay in completing them, and acknowledged that the labs and X-ray should have been obtained immediately per the physician’s orders but were not.