Staff at ARK Healthcare & Rehabilitation at Governor's Ho placed Resident #42 on a non-rebreather mask when the doctor had ordered a nasal cannula with humidified oxygen. The licensed practical nurse and two nursing assistants responsible for the resident's care had not received the facility's respiratory training that year.
The non-rebreather mask delivers high-flow oxygen through both nose and mouth during emergencies and requires a physician's order. Resident #42's doctor had prescribed low-flow humidified oxygen through a nasal cannula.
Federal inspectors found the resident using unhumidified oxygen through equipment meant for emergency situations on December 30.
The facility's own policy states non-rebreather masks deliver oxygen at 10 to 15 liters per minute and "are generally used for emergent situations and only for short periods of time." The policy requires maintaining the reservoir bag at least one-third full during inspiration.
APRN #1 told inspectors on December 30 at 11:15 AM that staff should "follow orders as they were written and to notify the physician if there were concerns or changes needed." The nurse practitioner explained that non-rebreather use "would require a doctor's order and high flow oxygen which would not be available on the resident room oxygen concentrators."
Room oxygen concentrators cannot deliver the high flow rates required for non-rebreather masks.
The Medical Director interviewed at 2:33 PM that same day said she expected "oxygen to be administered to residents as ordered by the doctor." She confirmed Resident #42 "should be receiving humidified oxygen if that was how it is ordered."
She stated that "a non-rebreather should not be used with low flow oxygen and would require an MD order to change the method of delivery from the ordered nasal cannula."
The facility provided appropriate respiratory education in 2025 that covered proper use of non-rebreather masks. The training materials identified that non-rebreathers "should be ordered by the provider and used with high flow oxygen."
None of the three staff members caring for Resident #42 attended the training.
The LPN supervising the resident's oxygen therapy failed to ensure proper equipment selection. Both nursing assistants involved in daily care administered oxygen through unauthorized equipment without questioning the orders.
Facility records show the respiratory training explicitly covered when different oxygen delivery methods should be used and the flow rates required for each type of equipment.
Non-rebreather masks feature a reservoir bag that fills with pure oxygen during exhalation and prevents room air from mixing with delivered oxygen during inhalation. The high concentration of oxygen delivered requires medical supervision and specific flow rates to function safely.
Nasal cannulas deliver lower concentrations of oxygen mixed with room air through small tubes placed in the nostrils. Humidification prevents drying of nasal passages during extended use.
The inspection found no evidence that medical staff had evaluated whether Resident #42 needed emergency oxygen therapy or higher flow rates. The resident continued receiving the wrong equipment until inspectors identified the violation.
Facility policy requires physician orders for all changes to oxygen delivery methods. Staff made the equipment change without medical authorization or documentation explaining why the ordered nasal cannula was insufficient.
The three untrained staff members remained responsible for oxygen administration to other residents despite missing mandatory respiratory education. The facility had not identified which employees lacked required training before the federal inspection.
Resident #42's medical record contained the original physician order for humidified oxygen via nasal cannula with no subsequent orders authorizing the non-rebreather mask or changes to flow rates.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ark Healthcare & Rehabilitation At Governor's Ho from 2025-12-30 including all violations, facility responses, and corrective action plans.