**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure continuous oxygen therapy was provided in consistent with professional standards of practice, related to failure to ensure the resident's record included accurate and active physician orders and on-going assessment of the resident's respiratory status and response to oxygen therapy, for two (#18 and #12) of two residents reviewed, resulting in Resident #18 experiencing respiratory distress requiring emergency hospitalization. Findings included: 1. Review of the admission record showed Resident #18 was originally admitted to the facility 2/22/24 and readmitted on [DATE] with diagnoses of acute bronchiolitis due to respiratory syncytial virus, acute chronic respiratory failure with hypoxia, and Chronic obstructive pulmonary disease (COPD). Review of a hospital History and Physicals for Resident #18 dated 5/5/25 revealed under history of presenting complaint, This is an [AGE] year-old male resident of an extended care facility with a history of COPD, congestive heart failure, chronic kidney disease, atrial fibrillation. He was brought to the emergency room with complaints of increased shortness of breath. At the time the EMS [Emergency Medical Services] got the patient 02 [oxygen] saturation was 82% on 2 L[liters] of nasal cannula oxygen. The patient was placed on nonrebreather mask and brought to the emergency room for further evaluation. In the emergency room, the patient transitioned to BiPAP [Bilevel Positive Airway Pressure]. This morning, he is currently doing better and placed back on nasal cannula oxygen, feeling much better compared to when he came to the hospital. The consultation showed, EMS responded to a call at the patient's rehabilitation facility, where they found the patient in distress with an oxygen saturation of 82% on 2L via a non-rebreather mask.The patient reported a decreased appetite over the past few days, with occasional nausea that has since resolved. He is currently on apixaban and furosemide for anticoagulation therapy. Chest x-ray shows central pulmonary vascular congestion, as well as right-sided small pleural effusion. He was started on IV [Intravenous] antibiotics and IV diuretics in the ER [Emergency Room]and was subsequently admitted to the ICU [Intensive Care Unit] for further management. Further review under medical decision making showed, the patient will be admitted for acute hypoxic respiratory distress. VBG [venous blood gas] in the ED [Emergency Department] shows hypercapnia [too much carbon dioxide (CO2) in the bloodstream]. Patient started on BiPAP to help blow off CO2. However, patient with worsening repeat measurements and becoming more sedated. Discussed with patient's power of attorney/who is his [family member]. Confirms that patient is a DNR [Do Not Resuscitate]/DNI [Do Not Intubate]. Will admit to ICU [intensive Care Unit], maximize supportive care. Started on IV antibiotics and IV diuretics. IV diuretics dosage carefully chosen due to history of hypotension requiring midodrine for Vaso [blood vessels] support. Family is not opposed to palliative care consult. On 5/7/25 at 12:23 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She stated she sent Resident #18 to the hospital on 5/5/25 because his oxygen saturations were low. She stated a CNA (Certified Nursing Assistant) was trying to transfer him from the bed when he gave out. She said, he was not himself, I called for him, he did not answer, he had a lethargic look, eyes fixed and not moving, I tried to arouse him. He was not responding. Staff D, LPN stated she asked the CNA to stay with him, and she went to get help. She stated another staff member got the DON (Director of Nursing) and the cart. Staff D, LPN stated, I continued to call him, and he did not respond, he was disoriented. Staff D, LPN stated Resident #18 was supposed to be on oxygen all the time, had compromised breathing, and had a similar episode before. Review of active physician orders for Resident #18 showed an oxygen order dated 3/28/25, O2 (oxygen) at 3L (liters) NC (nasal cannula). The order was noted verbally received. The order did not show scheduling or order administration scheduling details. Review of a Hospital Transfer Form dated 5/5/25 showed under respiratory treatments, the resident received O2 at 2L/Min (minute), Chronic. Review of an SBAR (Situation Background Assessment and Recommendation) form dated 5/5/25 showed the Change In Condition (CIC) reported on this CIC Evaluation are/were: Seems different than usual Tired, Weak, Confused, or Drowsy. Since this started it has gotten: Worse. At the time of evaluation resident/patient vital signs, weight and blood sugar were:- Blood Pressure: BP 142/60 - 5/5/2025 14:45 Position: Lying l/arm - Pulse: P 75 - 5/5/2025 14:45 Pulse Type: Regular - RR: R 19.0 - 5/5/2025 15:16 - Temp: T 98.0 - 5/5/2025 15:16 Route: Forehead (non-contact) - Pulse Oximetry: O2 88 % - 5/5/2025 14:45 Method: Oxygen via Nasal Cannula. The mental status evaluation showed increased confusion and disorientation. Functional status evaluation showed general weakness. Review of the notification section showed the Primary Care Physician (PCP) was notified with orders to send to ER (Emergency Room). Review of a physician encounter progress note dated 4/7/25 showed the Reason for Appointment: Cardiac Consultation. Chief Complaint / Nature of Presenting Problem: Cardiovascular disease management during admission for rehab. History Of Present Illness: . [Resident # 18] was admitted to the facility on [DATE] for COPD exacerbation with PNA (pneumonia) 2/2 (Secondary to) RSV (Respiratory Syncytial Virus). Today, patient is lying bed. He says he is doing ok. He voiced no concerning cardiovascular complaints. His BPs (blood pressures) continue to be low at times. Since last visit, patient was discharged to ALF (Assisted Living Facility). He then developed SOB (Shortness of Breath) and was readmitted to hospital for HF (Heart Failure) and COPD exacerbation. Upon discharge he was advised to use 3L NC O2. Returned to [name of facility] as of 3/27/2025. Nursing notes, Physician/ARNP (Advanced Registered Nurse Practitioner) notes, hospital records, labs, imaging, and VS (Vital Signs) trends were reviewed. Review of a document titled Respiratory Assessment and Recommendation Form - dated 4/9/25 showed Resident #18 was assessed and his FIO2 (Fraction of inspired oxygen) was documented at 3L. Breath sounds were documented to be diminished RLL [Right Lower Lobe] and LLL [left lower lobe]. The report confirmed an oxygen concentrator was in use. Review of a physician encounter progress note dated 4/21/25 showed Resident #18 was seen for a follow -up. Under respiratory assessment, reduced NC O2 to 3L diminished bases due to poor inspiratory effort was documented. Review of a care plan for Resident #18 initiated and revised on 3/6/25 showed the resident is at risk for altered respiratory status/difficulty breathing r/t (related to) recent RSV infection and pneumonia, CHF (Congestive Heart Failure), COPD and need for supplemental oxygen. Interventions included: Encourage adequate rest periods in between tasks/activities. Encourage and assist resident to elevate head of bed to facilitate breathing as tolerated. Monitor for s/sx. (Signs and Symptoms) of respiratory distress and report to MD PRN (Medical Doctor, As needed) increased Respirations; Decreased Pulse - oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Administer medication/inhalers/nebulizers as ordered. Administer oxygen as ordered. Monitor 02 saturations as ordered/PRN. Change tubing per MD order and PRN. Notify MD as indicated. Encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Use pain management as appropriate. Monitor/document side effects and effectiveness. Review of a skilled services progress note dated 5/5/25 showed Resident #18 was redirected for anxiety. Refused alternate meal or snacks. Resident lethargic with low saturation this afternoon. MD notified. Resident became more aroused gradually with 02 and non-rebreather. Resident then asked to go to ER. MD notified. EMS and family also notified. Review of a skilled services progress note dated 5/4/25 showed [Resident #18] has complaints of SOB (shortness of breath) this afternoon, PRN (as needed) nebulizer treatment provided and are effective. Review of a medication administration progress note dated 4/27/25 showed to encourage and assist the resident to elevate HOB (head of bed) for ease of breathing/SOB (shortness of breath) while lying flat every shift related to acute bronchiolitis due to respiratory syncytial virus, acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of a summary of skilled services note dated 4/17/25 showed, New orders received for desaturation [a decrease in the amount of oxygen in the blood]. Review of progress notes dated 4/17/25 showed Resident #18 had a CIC. At the time, his oxygen was 89%. The nurse practitioner was notified of desaturation despite O2 and nebulizer treatments. New orders for STAT (without delay) CXR (Chest X-Ray) and Lasix 40mg (milligrams) p.o. (by mouth) once. Review of a physician encounter note dated 4/15/25 showed, today patient is lying in bed. BP (blood pressure) remains labile with hypotension intermittently. Denies any recent falls. States breathing is worse, O2 4L increased recently. Under respiratory assessment it was noted, congestion and attempting to cough but cannot, increased NC 4L, diminished bases due to poor inspiratory effort. Review of physician orders for Resident #18 did not show the orders to increase oxygen to NC 4L as ordered on 4/15/25. On 5/7/25 at 12:23 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff, LPN denied knowing of the order to increase oxygen to 4L on 4/15/25 stating, he has always been on oxygen. I don't remember new orders. She stated it was a nursing expectation to monitor his oxygen with a pulse oximeter and document. She stated she could not speak of the MAR/TAR (Medication Administration Record /Treatment Administration Record) documentation that was missing. She stated to ask the DON. Review of a nursing note dated 4/9/25 showed Resident #18 exhibited sob and wheezing this morning. Upon assessment, resident's lung sounds are diminished both lower lobes. Writer gave resident his scheduled inhaler. Notified [staff member] with Respiratory therapy. Resident already has DuoNeb (a combination of two medicines) scheduled q6 (every 6 hours), we will continue that order and add PRN DuoNeb q4 (every 4 hours) for sob/wheezing. MD was notified. Review of a skilled services progress note for Resident #18 dated 4/7/25 showed Resident is A/O (alert and oriented) x3 is able to make needs known, Resident has HX (history) of Respiratory issues. Oxygen on at O2 3L via N/C, NEB TX (nebulizer treatment) in place Q6. Review of a nursing readmission evaluation dated 3/27/25 showed O2 94% on 3/27/2025 21:16 Method: Oxygen via Nasal Cannula. Resident respirations appear even and unlabored. The resident does not exhibit or report current respiratory issues. No respiratory issues noted/observed. On the question if the resident utilizes the following respiratory devices or equipment, it is noted None. Under notifications the assessment showed physician order treatment plan of care, medications discharge planning reviewed with resident and/responsible party. Medication reconciliation completed with medical provider. All orders confirmed and verified. Review of a progress note dated 3/23/25 showed patient complained of SOB, checked pulse Ox stating at 86%. Patient stated he wanted to go to the hospital. Notified MD of change, Per orders the patient will be sent out. Review of a Social Services progress note dated 3/14/25 showed, resident stated he has oxygen at ALF. He would like a portable one and resident has a wheelchair at facility. Review of an IDT(Interdisciplinary Team) progress note dated 3/6/25 showed resident is on supplemental oxygen and states he becomes short of breath of lying flat. Care plan was updated. Review of a general admission progress note for Resident #18 dated 3/5/25 showed upon arrival the resident's O2 was 90% - - 3/5/2025 18:04 Method: Oxygen via Nasal Cannula. Resident respirations appear even and unlabeled. The resident current exhibits or has reported the following respiratory symptoms: cough short of breath while lying flat short of breath at all times. The resident utilizes the following respiratory devices or equipment: oxygen. The residents along sounds are adventitious: right upper lobe has audible wheezes, right lower lobe has audible wheezes, and the left lower lobe has audible wheezes. Review of all progress note types for Resident #18 effective 3/7/25 to 5/8/25 did not show documentation related to on-going assessment of the resident's respiratory status and response to oxygen therapy. On 5/6/25 at 3:33 p.m. an interview was conducted with the DON. The DON stated Resident #18 went out to the hospital yesterday (5/5/25) because of low oxygen. She said, He has had a history of it, he was out of it. We called the doctor. He was able to stabilized with the O2 we administered. The DON stated Resident #18 came around before the EMS arrived. The DON stated he wanted to go the ER, so they sent him out due to shortness of breath. The DON stated she could not comment on the lack of oxygen monitoring documentation in the MAR/TAR. She said, I will look at it and get back with you. On 5/7/25 at 12:41 p.m. an interview was conducted with the DON, Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC). The RNC stated Resident #18 was sent out due to hypoxia (low levels of oxygen in the body tissues). Reviewing the residents electronic medical record (EMR), the RNC stated the resident had an oxygen order dated 3/7/25 -3/14/25 which was discontinued when he was sent out to the hospital. The RNC stated Resident #18 returned on 3/28/25. The DON, RNC, and NHA reviewed the residents record and confirmed the oxygen order was not transcribed completely. The RNC said, The nurse should have clarified the level of oxygen and how often it should be administered. They confirmed the order was put in wrong. The RNC stated the nurses were not able to document in the MAR/TAR because it was transcribed wrong. They all reviewed the MAR/TAR and confirmed the resident was not being monitored for oxygen use from 3/28/25 to 5/5/25 when the resident was sent out for emergency care. The DON said, I see, it was entered incorrectly. The RNC and DON could not speak of the order to increase oxygen on 4/15/25 and why the administration orders were not documented. 2. Resident #12 was originally admitted to the facility on [DATE], readmitted on [DATE] and discharged on 1/19/25. The resident was admitted with diagnoses to include chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of progress notes dated 1/19/25 showed Resident #12's family member came to the facility and was upset the resident was not on oxygen . Resident with a history of COPD. All orders checked, and resident has no orders for oxygen at this time. Hospital discharge paperwork reviewed, and oxygen was discontinued upon discharge from the hospital patient readmitted on [DATE]. The family member called 911 and the resident was transferred to the hospital stating, [Resident #12] needed to be on oxygen. Review of the TAR for Resident #12 dated 1/1/25 - 1/31/25 showed Oxygen: NC/mask continuous. Encourage and assist resident to use O2 at 2 liters. The TAR showed oxygen was administered on 1/1/25 and 1/2/25. It was discontinued on 1/3/25 when Resident #12 went to the hospital. The TAR did not show the oxygen order was reinstated upon returning from the hospital on 1/19/25. Review of the TAR for Resident #12 dated 12/1/24 - 12/31/24 revealed documentation of continuous oxygen administered at 2 liters, documented on day, evening, and night shift. Review of Resident #12's care plan initiated on 11/11/24 showed the resident had difficulty breathing related to diagnosis of chronic respiratory failure, COPD, and dependent on supplemental oxygen. Interventions included to administer oxygen as ordered. Monitor O2 saturations as ordered/change tubing per facility protocol/MD order. Notify MD as indicated. Review of physician orders summary report for Resident #12 showed the history of oxygen orders as follows: On 12/7/24: Oxygen 2L/min via nasal cannula at continuing as needed for (left blank) On 12/7/24: Oxygen 2L/min via nasal cannula at continuing. The review showed the most recent oxygen orders dated 12/7/24, were not discontinued. Review of an admission/readmission nursing evaluation dated 1/9/25, showed Resident #12 was readmitted from the hospital. Under notifications the evaluation showed: Physician order treatment of care medications discharge planning reviewed with Resident and/resident responsible party, medications reconciliation completed with medical provider. All orders confirmed and verified. This evaluation did not indicate discontinuing of oxygen orders for a resident with a known COPD diagnosis and historical use of oxygen. On 5/7/25 at 2:13 p.m. an interview was conducted with the DON and the RNC. The DON stated she had reviewed Resident #12's orders and said, He had no orders at the time. The DON reviewed the EMR and could not show physician orders to discontinue oxygen use for Resident #12 who was dependent on oxygen. The RNC reviewed the hospital discharge record for Resident #12 and stated he was admitted for cardiac issues. He confirmed the oxygen orders were not discontinued by the hospital. The RNC stated he would have expected the nurse to call the doctor and re-instate the oxygen orders. Requested and did not receive the facility's policy on oxygen administration.