The resident's spouse watched staff remove oxygen tubing on August 18 and told inspectors no one had returned to reconnect it by the following afternoon, despite a physician's order for two liters of oxygen delivered continuously through a nasal cannula.
When inspectors arrived at the resident's room at 11:10 a.m. on August 19, they found the oxygen concentrator sitting unused. The humidifier bottle sat on the floor. No tubing connected the machine to the resident.
The resident's spouse, present in the room, told inspectors his wife had not received oxygen since staff removed it the previous day along with the tubing. He said no staff had checked on the oxygen since he arrived that morning.
More than three hours later, at 2:45 p.m., the resident still wasn't receiving oxygen.
Licensed practical nurse LPN2, the unit manager, reviewed the resident's chart with inspectors and confirmed the order called for two liters per nasal cannula, continuously. She entered the room and examined the oxygen concentrator, finding tubing and a humidifier bottle present but the tubing stored in a bag. Neither the tubing nor the bottle carried required date labels.
The resident remained without oxygen.
During this same observation, the spouse repeated to LPN2 that tubing had been removed the previous day. He told the nurse they were planning to monitor the resident's oxygen levels themselves since no staff had checked.
At 4:00 p.m., inspectors returned to find the resident still without oxygen. Another nurse, LPN1, finally checked the resident's oxygen saturation, which measured 94%. Earlier that morning, it had been documented at 98%.
The clinical record revealed the contradiction at the heart of the violation. Despite the resident receiving no oxygen for over 24 hours, nursing staff had signed off that morning indicating the physician's order had been administered. The care plan reflected the same instructions for continuous oxygen at two liters via nasal cannula.
The facility's own oxygen administration policy requires licensed clinicians with demonstrated competence to administer oxygen via the specified route as ordered by a provider. The policy makes no provision for removing equipment and failing to reconnect it.
Federal inspectors documented their findings as a respiratory care violation with minimal harm or potential for actual harm. The inspection was conducted in response to a complaint.
On August 20, facility administrators including the regional director of clinical services, vice president of operations and director of nursing were notified of the violations during an end-of-day meeting.
The resident's experience illustrates a fundamental breakdown in basic nursing care. Oxygen therapy, when ordered continuously, requires staff to ensure uninterrupted delivery. The gap between what nurses documented and what actually occurred suggests either inadequate supervision or deliberate falsification of medical records.
The spouse's presence throughout the incident provided crucial witness testimony. His repeated statements to different staff members that no one had checked on the oxygen since its removal highlighted the systemic nature of the oversight failure.
The declining oxygen saturation from 98% to 94% over the course of the day demonstrated the medical impact of the deprivation. While inspectors classified the harm as minimal, oxygen levels below 95% can indicate respiratory compromise in elderly patients.
The facility's inability to maintain basic labeling requirements for medical equipment compounds the safety concerns. Unlabeled oxygen tubing and humidifier bottles create infection control risks and make it impossible to track when equipment should be replaced.
Monroe Health & Rehab Center operates at 1150 Northwest Drive in Charlottesville. The August inspection was triggered by a complaint, though inspectors did not specify the nature of the initial concern that brought them to the facility.
The violation occurred despite clear documentation in the resident's medical record and care plan specifying continuous oxygen delivery. The gap between written orders and actual care delivery represents a fundamental failure in nursing supervision and accountability.
No additional information was provided by facility administrators when confronted with the findings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monroe Health & Rehab Center from 2025-08-21 including all violations, facility responses, and corrective action plans.