Failure to Notify Provider and Obtain Order for Increased Oxygen Flow
Penalty
Summary
The deficiency involves the facility’s failure to notify a provider and obtain an order when nursing staff increased a resident’s supplemental oxygen beyond the prescribed level. The facility’s Condition or Status Change policy required the nurse to notify the physician or on-call physician when there was a significant change in the resident’s physical condition. The resident, who was cognitively intact and their own decision maker, had pneumonia and dependence on supplemental oxygen. On 10/12/25, after low oxygen saturation readings and abnormal lung sounds, the provider was notified and ordered oxygen at 3 LPM via nasal cannula to maintain oxygen saturation above 90%, along with documentation of liters per minute and oxygen saturation three times daily on the TAR. Review of the TAR showed that on 10/14/25 and into 10/15/25, staff documented the resident was receiving 4 LPM of oxygen each shift, with oxygen saturation levels ranging from 92% to 94%. A progress note on 10/14/25 at 2:39 PM also indicated the resident remained on 4 LPM of oxygen to keep saturation above 90%. However, the medical record contained no evidence of physician notification, no progress note documenting provider communication about the increase to 4 LPM, and no updated order authorizing this change in oxygen flow. Interviews with two PAs confirmed they would have wanted to be notified if a resident with pneumonia already on oxygen had their oxygen increased and why, and the DON verified that staff should have contacted the provider and obtained an order when oxygen was increased to 4 LPM.
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