Failure to Follow Oxygen Orders and Ensure Proper Oxygen Administration
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and physician orders for a resident with COPD and acute and chronic respiratory failure with hypoxia. The resident was admitted with diagnoses including unspecified COPD, orthopedic aftercare, and acute and chronic respiratory failure with hypoxia. An H&P dated 12/19/2025 documented that the resident did not have capacity to understand and make decisions, while an MDS dated 12/25/2025 indicated intact cognitive skills for daily decisions and a need for staff supervision with hygiene, toileting, and showering. Initial physician orders on 12/19/2025 directed oxygen at 4 L/min via nasal cannula, continuous with humidification for COPD and shortness of breath every shift, and a subsequent order dated 1/14/2026 changed the oxygen to 2 L/min via nasal cannula continuously every shift. On observation on 1/29/2026 at 9:19 a.m., the resident was found asleep at bedside with an oxygen concentrator running at 5 L/min via nasal cannula, but the nasal cannula was not connected to the resident and was instead hanging on a portable emergency light on top of the resident’s rolling table. A concurrent observation and interview with an RN confirmed that the oxygen was running at 5 L/min and that the nasal cannula was not attached to the resident. The RN called an LVN to obtain a pulse oximeter reading. At 9:25 a.m., the LVN placed the pulse oximeter on the resident’s left index finger, which showed an oxygen saturation of 92%, then reconnected the nasal cannula to the resident. The LVN stated that the resident’s oxygen saturation fluctuated between 80% and 90% while on 5 L/min, and the resident subsequently awoke, coughed up white phlegm, and the oxygen saturation increased to 91%. During interviews and record reviews, the ADON confirmed that the physician’s order dated 1/14/2026 specified oxygen at 2 L/min via nasal cannula and stated that a physician order was required to increase or titrate the oxygen, and there was no such order in place. The ADON stated that a resident not connected to ordered oxygen could experience shortness of breath. The LVN reported having observed the resident’s oxygen set at 5 L/min and acknowledged that the resident had a history of COPD and that giving high oxygen can cause shortness of breath. The DON stated that nurses should follow the physician’s order for continuous oxygen at only 2 L/min and that higher oxygen administration could result in hyperventilation. Review of facility policies showed that medications, including oxygen, must be administered in accordance with prescriber orders and that oxygen administration procedures require ensuring the proper flow of oxygen is being administered, which was not followed in this case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents with COPD and other comorbidities, one cognitively intact and one cognitively impaired, had physician orders for Ellipta and Breo Ellipta inhalers that included instructions to rinse the mouth with water after use, with one order specifying not to swallow the water. During observed morning medication administration, an LPN gave each resident their prescribed inhaled medication but did not prompt either resident to rinse and, for the second resident, to spit out the water as ordered. The LPN confirmed in interviews that the residents did not rinse their mouths after inhaler use, despite the documented orders and manufacturer guidelines requiring post-inhalation mouth rinsing.
A resident with COPD who was cognitively intact and receiving oxygen therapy had a physician order and facility policy requiring oxygen tubing changes on a monthly basis. Surveyor observation found the resident’s oxygen tubing labeled as last changed in January, well beyond the ordered interval, and an RN confirmed it should have been changed sooner. Review of the oxygen administration policy showed that tubing was to be changed monthly and PRN, but this was not done for the resident, resulting in a cited deficiency related to oxygen services.
Two residents who used oxygen, CPAP, and nebulizer treatments were found with respiratory equipment that was not maintained or stored in a sanitary manner. One resident’s room contained nasal cannulas on the floor next to an oxygen concentrator and a portable oxygen tank, none of which were dated, and a CPAP machine with undated tubing and an uncovered mask, contrary to facility policy requiring daily cleaning and bagging. Another resident’s nebulizer machine had tubing that was not dated. An LPN and a CNA confirmed these observations, and the DON acknowledged there was no policy for oxygen nasal cannulas or nebulizer tubing, despite stating that such tubing should be changed and dated weekly.
A resident with COPD, asthma, and atrial fibrillation was admitted with hospital orders to continue CPAP per home settings and a facility order for evening CPAP with 6–10 L O2 bleed-in. Documentation showed CPAP was given on two subsequent evenings, but there was no record of CPAP administration on the admission evening or of physician notification if it was unavailable. The admitting LPN reported the family left to retrieve the home CPAP and had not returned by shift end, while the evening LPN recalled providing oxygen but not whether CPAP was used. The resident’s family stated they brought in the CPAP that evening and informed staff, and the resident later reported CPAP had not been administered, indicating the ordered respiratory therapy was not provided or documented in accordance with facility policy.
Surveyors found that a resident with chronic respiratory failure and a tracheostomy did not have an Ambu (resuscitation) bag readily available at the bedside, despite facility policy requiring a handheld resuscitation bag with oxygen source to be easily accessible for emergencies; the RN confirmed the bag was missing and would have to be obtained from a crash cart if needed. In addition, another resident receiving continuous oxygen therapy at 3 L/min via nasal cannula had no corresponding physician order, which was confirmed on record review and by an LPN in social services.
Surveyors found that two residents were receiving oxygen therapy without valid physician orders, contrary to facility policy requiring orders for oxygen administration. One resident with asthma and other comorbidities was observed on 5 L/min via nasal cannula despite no active order, and staff, including the DON, confirmed both the absence of an order and that the resident should have been on a lower continuous flow. Another resident with multiple complex diagnoses and total dependence on staff had a care plan and progress notes indicating use of 2 L/min oxygen via nasal cannula for pneumonia, yet no corresponding oxygen order appeared on the MAR or TAR, and leadership confirmed no order existed.
Failure to Ensure Mouth Rinsing After Inhaled Respiratory Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory care by not ensuring residents rinsed their mouths after administration of prescribed inhaled respiratory medications. For one resident admitted with COPD, emphysema, and heart disease, with intact cognition and needing assistance with ADLs, the physician’s order for Ellipta 62.5 mcg inhaler specifically included rinsing the mouth with water after use. During an observation of the morning medication pass, an LPN administered the Ellipta inhaler but did not prompt the resident to rinse his mouth afterward, and the LPN confirmed in interview that the resident did not rinse following administration. A second resident, admitted with COPD, high blood pressure, and anxiety, had impaired cognition with a low BIMS score and required staff assistance with ADLs. This resident had a physician’s order for Breo Ellipta 100-25 mcg inhaler with instructions to rinse the mouth with water after use and not to swallow. Review of the MAR confirmed this order. During observation, the same LPN administered the Breo Ellipta inhaler but did not prompt the resident to rinse and spit out the water into a cup, and confirmed in interview that this was not done per the physician’s order. Manufacturer guidelines for Breo Ellipta state that patients should rinse their mouth with water without swallowing after inhalation to help reduce the risk of oropharyngeal candidiasis (thrush).
Failure to Change Oxygen Tubing per Physician Order and Policy
Penalty
Summary
A deficiency occurred when the facility failed to change oxygen tubing as ordered by the physician and as required by facility policy for a resident receiving oxygen therapy. The resident, admitted with diagnoses including chronic obstructive pulmonary disease, was cognitively intact and had a physician order dated 01/02/26 directing that oxygen tubing be changed monthly. On 04/27/26 at 10:22 A.M., observation showed the resident’s oxygen tubing was labeled as last changed on January 20 (no year), indicating it had not been changed according to the monthly schedule. During an interview at 10:30 A.M. the same day, an RN confirmed that the tubing was dated January 20 (no year) and acknowledged it should have been changed sooner. Review of the facility’s “Administration of Oxygen” policy, effective 05/2018, showed that oxygen tubing was required to be changed monthly and as needed, which was not followed in this case. This deficiency was cited as non-compliance under Complaint Number 2989132 and involved one of two residents reviewed for oxygen services in a facility with a census of 49.
Failure to Maintain and Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The deficiency involves the facility’s failure to maintain and store respiratory equipment in a sanitary manner for two residents who used oxygen, CPAP, and nebulizer treatments. For one resident with multiple diagnoses including asthma, heart failure, chronic kidney disease, obstructive sleep apnea, and use of dialysis services, surveyors observed a nasal cannula lying on the floor next to an oxygen concentrator in the resident’s private room, with no label indicating the date it was initiated. A CPAP machine was also observed on the nightstand with tubing that was not dated and a mask that was not covered to protect it from dust and germs. Additionally, a portable oxygen tank was present with another nasal cannula on the floor that was also not dated. An LPN confirmed these observations and stated that oxygen and CPAP tubing should be dated, nasal cannulas should not be on the floor, and CPAP masks should be cleaned and bagged daily after use. The facility’s CPAP/BiPAP Cleaning policy required CPAP masks to be cleaned and dried daily after use and then stored in a plastic bag. For a second resident with diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, surveyors observed a nebulizer machine on the nightstand with tubing that was not labeled with the date it was initiated. A CNA confirmed that the nebulizer tubing was not dated. During an interview, the DON stated that the facility did not have a policy or procedure regarding the maintenance of oxygen nasal cannulas and nebulizer tubing, and further confirmed that oxygen nasal cannulas and nebulizer tubing should be changed and labeled with the date of initiation once weekly. This lack of policy and failure to follow existing CPAP cleaning and storage requirements resulted in respiratory equipment for both residents not being maintained and stored in a sanitary manner.
Failure to Administer Ordered CPAP Therapy on Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s continuous positive airway pressure (CPAP) therapy was administered according to physician orders on the day of admission. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease, asthma, and atrial fibrillation, was admitted with hospital discharge orders to continue CPAP per home settings. Facility physician orders dated the day after admission directed application of the home CPAP with 6–10 liters of oxygen bleed-in every evening shift. Review of the Treatment Administration Record showed CPAP was documented as applied on the two evenings following admission, but there was no documentation that CPAP was administered on the admission date, despite the discharge orders specifying continuation of CPAP. Interviews further clarified the events leading to the deficiency. The admitting LPN stated the resident had an order for home CPAP every evening and that the family went home to retrieve the CPAP machine but had not returned by the end of her shift. The evening-shift LPN confirmed the resident received oxygen that evening but could not recall whether the CPAP machine had been brought in or used. In contrast, the resident’s representative reported that the family did bring the CPAP machine to the facility that evening and informed both the nurse and the Respiratory Therapist, and that the resident later reported staff had not administered the CPAP. The Regional Nurse confirmed there was no documentation in the medical record that CPAP was administered as ordered on the admission date or that the physician was notified if CPAP was not available, despite facility policy requiring review of physician orders and appropriate CPAP/BiPAP support.
Failure to Maintain Tracheostomy Emergency Equipment and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory and tracheostomy-related care and equipment for two residents. One resident, admitted with chronic respiratory failure with hypoxia, tracheostomy status, COPD, heart failure, and chronic pulmonary edema, had active orders for 28% humidified oxygen via tracheostomy collar to maintain oxygen saturation above 90%, with tracheostomy care every shift and a full code status. Her care plan identified risk for respiratory distress, decannulation, and infection, with interventions including humidified oxygen and tracheostomy care per orders and protocol. During an observation of tracheostomy care performed by an RN, the resident’s room was checked for emergency medical supplies related to her tracheostomy. All necessary emergency equipment was present except for an Ambu (resuscitation) bag, which could not be located despite the nurse searching the room. The RN acknowledged that an Ambu bag should be readily accessible in the room for emergencies and stated she would need to leave the room or have someone obtain one from the crash cart if needed. The facility’s tracheostomy care policy specified that a handheld resuscitation bag with attached oxygen source must be readily available for easy access in an emergency. The deficiency also includes the facility’s failure to ensure a physician’s order was in place for oxygen administration for another resident prior to its use. This resident was admitted with diagnoses including major depression and hypertension. An MDS assessment documented that the resident received continuous oxygen therapy. During an observation, the resident was noted to have oxygen in place at 3 L/min via nasal cannula. Review of current orders showed there was no physician’s order for the resident to receive oxygen. In a subsequent observation and interview, the resident was again seen resting in bed with oxygen in place, and a social services staff member, who is also an LPN, confirmed that there was no order in place for the oxygen therapy being administered.
Plan Of Correction
1. On 5/6/26, Director of Nursing verified an ambu bag at Resident #9's bedside. On 4/13/26 the Licensed Nurse contacted the physician and obtained an order for oxygen use for Resident #39. 2. Like Residents are identified as residents who utilize a tracheostomy within in the facility. Utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure they have an Ambu bag at bedside. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize oxygen within the facility. Utilizing the Respiratory Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure residents utilizing oxygen have physician orders for oxygen use in place. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Physician Orders, the emergency equipment to be at bedside for residents with a tracheostomy and the Use of Oxygen Policies to include obtaining physician orders for use of oxygen. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit all residents with a tracheostomy weekly for four weeks, beginning 5/14/26 to ensure they have an Ambu bag at bedside. Noncompliance noted from audits will be corrected with emergency equipment at bedside for residents with a tracheostomy. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Respiratory Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents utilizing oxygen have physician orders for oxygen use in place. Noncompliance noted from audits will be corrected with physician orders obtained for resident with oxygen use in place. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Oxygen Administered Without Valid Physician Orders to Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper administration of oxygen and to maintain valid physician orders for oxygen use for two residents. For one resident with asthma, morbid obesity, edema, lymphedema, muscle weakness, and anxiety, the care plan identified a risk for respiratory distress related to asthma and included interventions to administer oxygen and monitor oxygen saturation as ordered. However, review of active physician orders showed no current order for oxygen, while observations on two occasions revealed the resident was receiving oxygen via nasal cannula at five liters per minute. Multiple staff interviews, including with two LPNs and the DON, confirmed the resident was on five liters of oxygen without an active physician order. The DON stated the resident should receive continuous oxygen at two to three liters per minute, reported the resident had behaviors of turning up the oxygen, and acknowledged that oxygen is a medication for which staff should verify the five rights of medication administration and confirm an active physician order. For a second resident with extensive medical diagnoses including metabolic encephalopathy, severe protein-calorie malnutrition, psychosis, mood disorder, major depressive disorder, multiple nutritional deficiencies, tachycardia, liver disorder, anxiety disorder, pericardial effusion, and hypotension, the quarterly MDS showed no cognitive impairment and total dependence on staff for care. The care plan documented a diagnosis of pneumonia with an intervention to administer oxygen as ordered. Progress notes over several days documented that this resident was on two liters of oxygen via nasal cannula, with oxygen saturations in the mid to high 90s, and referenced an x-ray showing perihilar infiltrates and an order received for oxygen. However, review of the MAR and TAR for the month revealed no oxygen order, and the Executive Director confirmed there was no oxygen order for this resident. The facility’s oxygen administration policy stated that oxygen is to be administered under physician orders, which was not followed in these cases.
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