Incomplete Oxygen Order for Resident with Chronic Respiratory Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not ensuring that a physician’s order for supplemental oxygen included the frequency of administration. A resident admitted with chronic respiratory failure with hypoxia, COPD, obstructive sleep apnea, emphysema, and MRSA carrier status had a physician order dated 09/14/25 for supplemental oxygen at 2 L/min, but the order did not specify how often or under what circumstances the oxygen should be administered. During observation on 02/10/26, the resident was seen in bed wearing a nasal cannula connected to an oxygen concentrator at the bedside. In an interview on 02/13/26, the DON confirmed that the oxygen order should indicate the frequency of administration and acknowledged that it did not, resulting in incomplete respiratory care orders for this resident. The survey findings state that this failure to specify oxygen frequency in the medical order was identified for 1 of 3 residents reviewed for respiratory care and was likely to result in residents receiving too much or not enough oxygen, which could lead to worsening of their conditions.
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