Failure to Administer Oxygen per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy in accordance with physician orders and facility policy for one resident. Facility policy dated February 27, 2026, required that residents needing oxygen have a physician’s order specifying the oxygen flow rate. An annual MDS assessment for Resident 5 dated January 22, 2026, documented moderate cognitive impairment, a need for staff assistance with daily care, diagnoses including heart failure, and receipt of supplemental oxygen. Physician’s orders dated February 13, 2024, directed that the resident receive oxygen at 3 L/min via nasal cannula. On March 3, 2026, at 11:25 a.m., the resident was observed sitting in a wheelchair in her room with a nasal cannula connected to a portable oxygen tank that was empty; an LPN confirmed the tank was empty and replaced it with a full one. Later that day at 12:04 p.m., the resident was observed in the dining room with a nasal cannula attached to a portable oxygen tank set at 2 L/min, despite the physician’s order for 3 L/min. Another LPN confirmed the flow rate discrepancy between the tank setting and the physician’s order. The DON confirmed that oxygen should have been administered according to the physician’s orders.
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