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Based on observation, medical record review and interviews the facility failed for 1 of 3, (patient #1), patients to ensure that oxygen is delivered as ordered by the physician.

Findings:

1. Review of the medical record for patient #1 revealed revealed that the patient was transferred to the facility from a acute care hospital on 09/15/2012 with the following medical conditions Congestive heart failure, ischemia cardiomyopathy, status post respiratory failure, pneumonia, and chronic obstructive pulmonary disease.

2. Review of the medical record revealed that the patient was placed on 3 liters/minute of oxygen delivered by a nasal cannula on admission that was later decreased to 2 liters/minute. The patient was also placed on C-PAP at night for the treatment of sleep apnea. Nursing notes revealed that the patient's oxygen saturation levels were measured every 4 hours.

3. Observation on 10/04/2012 at 10:30 AM of resident #1 revealed the patient sitting in a recliner right side of his bed. The bed was observed to be stripped of linen. A oxygen flow meter that was located at the left side of the head of the bed was observed to be set at a flow rate of 2 liters/minute and the oxygen tubing, (nasal cannula), was observed wrapped around the flow meter. At that time the patient's spouse entered the room and state, "they forgot to put the oxygen back on". When the patient was asked if that was the case he stated that they had forgot to put the oxygen on after getting him out of bed. When asked if he was to use the oxygen at all times the patient stated that he was to be used all the time. The patient's wife agreed and placed the nasal cannula back on the patient.