Failure to Provide Ordered Oxygen Therapy and Maintain Readily Available O2 Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards for two residents who required or potentially required oxygen (O2) therapy. For one resident with impaired gas exchange related to respiratory failure and pulmonary edema, physician progress notes over several weeks documented fluctuating O2 needs, including low O2 saturations on room air, use of O2 at 1–4 LPM, and instructions to continue O2 supplementation and wean as tolerated. However, on the date of survey observation, the resident was seen outside the room without O2, and the bedside oxygen concentrator was present but turned off and without tubing attached. The physician’s orders on that date referenced only a room air trial, with no active or discontinued O2 orders in the record. Nursing progress notes were inconsistent, alternately documenting no O2 in use and O2 via nasal cannula on different days, and the resident’s care plan, while addressing impaired gas exchange, did not include O2 use as an intervention. The MDS for this resident also lacked documentation of O2 use. The DON stated her expectation that O2 use be ordered in the EHR and reflected in the care plan and MDS. For the second resident, admitted with Parkinson’s disease, dysphagia, and weakness, physician orders directed O2 at 1–4 LPM via nasal cannula as needed. Despite this standing PRN order, surveyors twice observed that no O2 equipment was present in the resident’s room on separate days. During interview, the DON confirmed that the resident had an order for O2 at 1–4 LPM as needed and stated her expectation that appropriate O2 equipment should be present and available in the resident’s room. These findings show that the facility did not ensure ordered O2 therapy was administered per provider orders for one resident and did not ensure necessary respiratory equipment was readily available for another resident with an active O2 order.
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.