The nurse at CareOne at Wayne told the inspector on October 29 that "the oxygen order was 2 lpm, but the actual oxygen liters the resident is getting is above 2 lpm." She acknowledged "it is not supposed to be above 2 lmp" and immediately reduced the oxygen flow from 3 liters per minute to the prescribed 2 liters.
The resident, identified only as Resident #3, was admitted with shortness of breath and congestive heart failure. The heart condition means the organ cannot pump blood effectively enough to supply the body with adequate circulation.
Federal inspectors observed the violation twice during their complaint investigation. At 9:46 AM, they found the resident awake and alert in bed, connected to a nasal cannula delivering 3 liters of oxygen per minute from a wall outlet. More than an hour later, at 11:02 AM, the resident remained on the excessive oxygen flow.
Only when inspectors confronted the Licensed Practical Nurse did she acknowledge the error and correct it.
The resident's medical records showed an active physician order for "oxygen at 2 lpm via nasal cannula continuously, every shift" that had been entered that same day. The care plan, initiated October 28, specifically focused on respiratory impairment risk related to the patient's congestive heart failure, with interventions including "administering oxygen per physician order."
The facility's own oxygen administration policy, last revised in October 2010, states that staff should "start the flow of oxygen at the rate of 2 to 3 liters per minute" unless otherwise ordered. But the doctor had specifically ordered 2 liters, not the policy's upper range.
For patients with congestive heart failure, precise oxygen delivery is critical. Too much oxygen can suppress the body's natural breathing drive and worsen respiratory function in some cardiac patients.
The nursing home's administrator and Director of Nursing met with inspectors at 1:16 PM to discuss the violation but provided no additional information about how the error occurred or what steps they would take to prevent similar incidents.
CareOne at Wayne's medical record system combines both electronic and paper documentation. Inspectors noted that no Minimum Data Set assessment tool was found in the resident's hybrid medical records, though this standardized evaluation is typically used to facilitate care management for nursing home patients.
The oxygen overdose represented what federal regulators classified as "minimal harm or potential for actual harm" to the resident. The violation affected what inspectors described as "few" residents at the facility.
The inspection was conducted in response to a complaint filed against the nursing home. Federal investigators determined that CareOne at Wayne "failed to ensure that the physician's orders were followed according to the standard of clinical practice."
This wasn't a case of staff misunderstanding a complex medical order. The physician's instruction was clear: 2 liters per minute of oxygen via nasal cannula, continuously. The Licensed Practical Nurse knew the correct dosage but had been delivering the wrong amount anyway.
The resident remained conscious and alert throughout the inspector's observations, but the potential consequences of oxygen overdose in heart failure patients can include respiratory depression and worsened cardiac function.
CareOne at Wayne must now submit a plan of correction to federal regulators detailing how it will prevent similar medication errors. The facility has 14 days from receiving the inspection report to make its response public.
The October 29 inspection focused specifically on respiratory care practices following the complaint. Federal investigators reviewed the resident's complete medical history, care plans, and physician orders to document the oxygen administration failure.
No other respiratory care violations were cited during this complaint investigation, suggesting the oxygen overdose was an isolated incident rather than a systematic problem with the facility's breathing treatment protocols.
The resident's admission record showed multiple respiratory challenges, making accurate oxygen delivery even more critical for their recovery and ongoing care management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careone At Wayne from 2025-10-29 including all violations, facility responses, and corrective action plans.