Failure to Specify Oxygen Administration Parameters in Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not ensuring that a resident’s oxygen order specified how it was to be administered. The resident was admitted with multiple diagnoses, including dementia, anxiety, bipolar disorder, major depressive disorder, seizure disorder, and COPD. Record review showed a physician’s order dated 02/24/26 for oxygen at 1–3 LPM via nasal cannula using an oxygen concentrator and/or oxygen tank, but the order did not indicate whether the oxygen was to be given continuously or on an as-needed basis. During an observation in the activity room on 03/10/26, the resident was seen wearing a nasal cannula connected to a portable oxygen concentrator. In a subsequent interview on 03/12/26, the DON confirmed that the oxygen order for this resident did not specify the frequency of use, such as as-needed or continuous, and acknowledged that it should have included this information. This lack of specificity in the physician’s order constituted the failure to provide respiratory care according to professional standards for this resident.
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