The resident, readmitted in December with chronic respiratory failure, emphysema, and a fractured right pubis, had a physician's order for oxygen at 2-3 liters per minute to keep oxygen saturation at 90% or higher. Staff were also ordered to change oxygen tubing weekly.
Instead, inspectors found the patient receiving only 1 liter per minute during their December 26 visit. The oxygen tubing hadn't been changed since December 7, nearly three weeks earlier, despite the weekly requirement.
When investigators reviewed the patient's medical records with the registered nurse on duty, they pointed out the discrepancy. The nurse acknowledged they should be following the physician's order.
The facility's medication administration record showed no documentation that oxygen was given on December 26, the day inspectors arrived.
The patient's care plan specifically noted she was "at risk for alteration in respiratory functioning" due to her chronic respiratory failure and emphysema. The intervention plan called for administering "oxygen and other medication and respiratory treatments as ordered."
Facility policy required oxygen therapy to be "administered to patients as indicated upon a physician's order" with oxygen setups changed every seven days. Another policy mandated that "all resident medications, treatment and plan of care must be in accordance with the licensed physician's orders."
Inspectors informed both the administrator and director of nursing about their findings on December 26.
The violation affected few residents but posed potential for actual harm, according to the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmony Park Ridge from 2025-12-30 including all violations, facility responses, and corrective action plans.
