Failure to Administer Oxygen at Prescribed Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered oxygen therapy was administered at the prescribed setting for a resident requiring continuous oxygen. The resident, an older female with chronic pulmonary edema, acute respiratory failure with hypoxia, and pleural effusion, had an active physician order dated 3/17/2026 for continuous oxygen at 3 liters per minute via nasal cannula every shift. The resident’s MDS assessment indicated moderate cognitive impairment and documented oxygen therapy as a treatment performed on admission and while a resident. The care plan identified a behavioral problem in which the resident removed the nasal cannula and chewed on the oxygen tubing, with an intervention to administer medications as ordered. On 3/19/2026 at 10:56 a.m., surveyors observed the resident in bed with oxygen being delivered via nasal cannula from a concentrator set at 2.5 liters per minute instead of the ordered 3 liters. LVN A was observed checking and then adjusting the concentrator setting to 3 liters per minute in response to this finding. Earlier that morning, LVN A reported having checked the oxygen setting and stated it was at 3 liters, with an oxygen saturation of 98% at 9:30 a.m. The ADONs reported that they conducted rounds each morning, including checking oxygen settings, and that managers made Quality of Life rounds to address issues such as oxygen settings. The facility’s policy on Medication-Treatment Administration and Documentation Guidelines required medications to be administered according to the physician’s order, which was not followed at the time the oxygen concentrator was found set below the prescribed rate.
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