F0695

D

Lack of Physician Order for Continuous Oxygen Therapy

Kannapolis, North Carolina Survey Completed on 03-18-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to obtain and maintain a physician’s order for continuous oxygen therapy for a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The resident was admitted with these diagnoses and had a physician progress note indicating chronic respiratory failure on 3 liters of oxygen via nasal cannula. A quarterly MDS documented that the resident was cognitively intact and used oxygen, and the active care plan identified COPD with risk for respiratory distress, with an intervention for oxygen via nasal cannula as ordered. An NP progress note later documented that the resident utilized 3 liters of oxygen continuously, and nursing progress notes over several months showed the resident was using oxygen continuously.

Despite this ongoing use, reviews of the resident’s physician orders for multiple consecutive months showed no order for oxygen. During several observations, the resident was seen in bed with oxygen flowing at 2 liters via nasal cannula and reported using oxygen continuously, without signs of shortness of breath at those times. A medication aide who frequently cared for the resident confirmed the continuous oxygen use, believed the resident used 2 liters, and verified there was no corresponding order in the medical record, without being able to explain the omission. The ADON also confirmed the resident required continuous oxygen for COPD, verified there was no order for continuous oxygen in the record, and stated that an order should have been present. An NP later stated that at the last assessment she made no changes to the plan of care, which included continuous oxygen at 3 liters via nasal cannula, and that she would expect the facility to have an order for this therapy.