Resident #3, who has acute respiratory failure with hypoxia and congestive heart failure, was given oxygen at 2 liters per minute through a nasal cannula from at least September 3 through September 28. During that entire period, no doctor had ordered the oxygen therapy that staff administered daily.
The resident's care plan specifically called for oxygen administration "to maintain blood oxygen saturations above 92%" due to her "ineffective gas exchange and respiratory illness." Yet when inspectors reviewed her physician's order summary on September 28, they found no authorization for oxygen anywhere in her medical record.
LVN A discovered the missing order during the inspection. After reviewing the resident's chart, she told inspectors "the resident did not have an order for oxygen and Resident #3 should have an order since the resident received oxygen."
She explained the potential consequences: respiratory distress if the resident didn't receive oxygen, or harm from receiving too much oxygen without proper medical oversight.
The resident's medical history made the unauthorized treatment particularly concerning. Her physician's progress notes from September 24 documented acute respiratory failure with hypoxia, high blood pressure, congestive heart failure, and pneumonia. These conditions require careful monitoring of oxygen levels and precise dosing.
Despite her serious respiratory conditions, the resident's quarterly assessment from September 7 didn't even indicate she was receiving oxygen therapy. The form showed she had perfect cognitive function with a score of 15 out of 15, meaning she was fully aware of her treatment.
Records show staff measured her blood oxygen saturation 18 times between September 3 and September 28 while administering the unauthorized oxygen. Each measurement occurred while she received treatment that lacked any medical authorization.
When inspectors observed the resident on September 28 at 8:52 AM, she was in bed receiving oxygen at 2 liters per minute through the nasal cannula, just as she had been for weeks without a doctor's order.
The Executive Clinician acknowledged the violation during interviews. "When a resident received oxygen, they should have an order for the oxygen," she told inspectors on September 29. She said the harm of missing orders "could result in the oxygen treatment not being monitored."
She and the Assistant Director of Nursing were responsible for ensuring accurate clinical records and reviewing hospital orders when residents were admitted or readmitted. The resident had been readmitted to the facility, but staff failed to obtain proper oxygen orders during that process.
The Executive Director confirmed that oxygen administration required documentation in the clinical record, care plan, and physician orders. "The harm of not having an order for oxygen was there would not be any documentation that it was ordered by the physician and any treatment would have to have a doctor's order," he said.
The facility's own oxygen administration policy, revised in October 2010, explicitly required staff to "verify that there is a physician's order for this procedure" and "review the physician's orders or facility protocol for oxygen administration."
Staff violated this basic safety protocol for nearly a month while treating a resident whose respiratory failure and heart conditions made proper oxygen monitoring critical.
The unauthorized treatment continued even as staff documented the resident's oxygen saturations in her electronic medical record. These measurements showed ongoing monitoring of a therapy that lacked any medical authorization, creating a paper trail of the violation.
The resident's care plan acknowledged her need for oxygen therapy due to her serious respiratory conditions, but the facility failed to secure the physician's order required by both federal regulations and their own policies.
The violation affected a resident whose cognitive abilities were intact, meaning she was fully aware of receiving daily oxygen therapy that staff administered without proper medical oversight for nearly four weeks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Estates At Shavano Park from 2025-09-29 including all violations, facility responses, and corrective action plans.