Failure to Ensure Proper Oxygen Administration and Use of Nasal Cannula
Penalty
Summary
Surveyors identified a deficiency in the provision of respiratory care for one resident with COPD and asthma who was ordered to receive 3 LPM of oxygen continuously. Record review showed a physician’s order dated 09/25/25 for continuous oxygen at 3 LPM. During an observation and interview on 11/17/25 at 2:00 PM, the resident was in bed with a nasal cannula in place but with the nasal prongs resting on the left cheek instead of inside the nostrils. The resident stated he needed oxygen because of COPD and reported that the nasal cannula would not stay in place and kept slipping to his left cheek; when he repositioned it, it again moved back to his cheek. A sign above the bed indicated the resident was to be on 3 LPM of oxygen continuously, but the oxygen concentrator was observed to be set at 3.5 LPM. At 2:06 PM the same day, an LPN confirmed that the nasal cannula was incorrectly positioned on the resident’s cheek and should have been in his nose, and also confirmed that the physician’s order was for 3 LPM while the concentrator was set at 3.5 LPM. The LPN stated that staff were not supposed to adjust residents’ oxygen without notifying the provider and obtaining an order. On a subsequent observation on 11/19/25 at 11:18 AM, the resident was not wearing the nasal cannula at all, while the concentrator remained set at 3 LPM; another LPN confirmed the resident was supposed to be wearing oxygen continuously. The Regional Clinical Nurse later confirmed that staff should contact the provider for oxygen adjustments, that the order remained for 3 LPM continuously, and that there was no documentation explaining why the oxygen had been set at 3.5 LPM.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.