F0695

D

Failure to Follow Oxygen Orders and Maintain Sanitary Oxygen Equipment

Hilliard, Ohio Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide oxygen therapy services according to physician orders and to maintain oxygen equipment in a sanitary condition for two residents. For one resident with sepsis due to MRSA and pulmonary hypertension, the MDS indicated continuous oxygen use and a physician order dated 3/11/26 specified oxygen at 3 L/min via nasal cannula continuously. On observation, the oxygen concentrator gauge showed delivery at 2 L/min while the resident was resting in bed. A concurrent interview with the RN present confirmed the oxygen was set at 2 L/min, and the RN further confirmed that the physician’s order required 3 L/min. The facility’s SOP for Administration of Oxygen directed staff to verify the physician’s order and to administer oxygen as ordered.

For another resident with diagnoses including paroxysmal atrial fibrillation, GI hemorrhage, acute respiratory failure with hypoxia, and COPD, the admission MDS showed the resident was cognitively intact and receiving oxygen therapy. Physician orders dated 2/23/26 required oxygen at 2 L/min via nasal cannula continuously and monthly tubing changes. During observation, the nasal cannula was found hanging on the side of the bed, not stored in a sanitary bag, with the nasal prongs pressed against the side of the hospital bed. A CNA present then placed the same nasal cannula on the resident without replacing it and confirmed it should have been stored in a sanitary bag when not in use. A subsequent observation with an RN showed the oxygen concentrator set at 2.5 L/min, above the ordered 2 L/min, and the RN confirmed the discrepancy without making an adjustment. The facility’s oxygen administration policy required oxygen to be administered as ordered and equipment to be maintained in a clean and sanitary manner when not in use.