BRUNSWICK, GA - A complaint investigation at Gracemore Nursing and Rehab found that staff administered incorrect oxygen levels to a resident with chronic respiratory disease, potentially placing the patient at risk for serious medical complications.
Oxygen Therapy Delivered at Wrong Flow Rate
During a March 2025 inspection, surveyors discovered that a resident with chronic obstructive pulmonary disease and chronic respiratory failure was receiving oxygen at 3 liters per minute instead of the prescribed 2 liters per minute. The error continued for an undetermined period before being identified by investigators.
The resident, who has moderate cognitive deficits, was prescribed oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath or compromised oxygen saturation levels. However, observations conducted over multiple time periods revealed the oxygen concentrator was consistently set to deliver 3 liters per minute - 50% higher than the prescribed dose.
When a Licensed Practical Nurse was questioned about the discrepancy during the inspection, she confirmed the physician's order called for 2 liters per minute and acknowledged that "the O2 flowmeter was set on the wrong flow rate of 3 LPM." The nurse explained that nursing staff were responsible for checking oxygen flow rates daily to ensure accuracy.
Medical Risks of Incorrect Oxygen Administration
Oxygen therapy requires precise delivery because both too little and too much oxygen can cause serious health complications. For patients with chronic obstructive pulmonary disease, excessive oxygen can suppress the body's natural drive to breathe, potentially leading to carbon dioxide retention and respiratory failure.
Patients with COPD have adapted to higher carbon dioxide levels and lower oxygen levels in their blood. Their breathing is primarily driven by low oxygen levels rather than high carbon dioxide levels like healthy individuals. When given too much supplemental oxygen, this drive to breathe can be diminished, causing dangerous carbon dioxide buildup.
The prescribed 2-liter flow rate was specifically calculated for this resident's medical condition and needs. Delivering oxygen at higher rates without medical supervision could mask symptoms that indicate worsening respiratory status or create a dangerous dependency on higher oxygen levels.
Systemic Failures in Oxygen Management
The Director of Nursing reported being unaware of the incorrect oxygen flow rate until investigators brought it to her attention during the survey. This suggests a breakdown in the facility's daily monitoring systems designed to ensure proper oxygen delivery.
According to the facility's own Oxygen Administration policy, staff must verify physician orders and review care plans to assess residents' special needs. The policy emphasizes the importance of following physician orders precisely and conducting regular assessments.
The fact that multiple nursing staff failed to identify or correct the error over time indicates systemic issues with medication administration protocols. Daily oxygen flow rate checks, as acknowledged by nursing staff, were either not being performed or were ineffective in catching the discrepancy.
Industry Standards for Respiratory Care
Proper oxygen therapy administration is a fundamental aspect of nursing home care, particularly for residents with respiratory conditions. Federal regulations require facilities to provide safe and appropriate respiratory care based on physician orders and residents' assessed needs.
Standard protocols mandate that nursing staff verify oxygen flow rates match physician orders during each shift and document these checks. Any changes to oxygen therapy must be authorized by the attending physician and properly documented in the resident's medical record.
The resident's care plan should have included specific monitoring requirements given their chronic respiratory conditions and moderate cognitive deficits. Regular oxygen saturation monitoring and respiratory assessments are essential for patients requiring supplemental oxygen therapy.
Additional Issues Identified
The inspection narrative indicates this was part of a broader complaint investigation, though the specific nature of other concerns was not detailed in the available documentation. The oxygen administration error was classified as having "minimal harm or potential for actual harm" affecting few residents.
The facility's failure to follow its own established policies regarding oxygen administration verification represents a significant gap in quality assurance processes. This type of medication error could have been prevented through proper implementation of existing safety protocols.
The investigation findings highlight the importance of robust oversight systems in nursing facilities, particularly for residents with complex medical conditions requiring specialized treatments like oxygen therapy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gracemore Nursing and Rehab from 2025-03-09 including all violations, facility responses, and corrective action plans.
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