Resident 42 was supposed to receive humidified oxygen through a nasal cannula. Instead, staff fitted the resident with a non-rebreather mask connected to unhumidified oxygen from a room concentrator.
The equipment switch violated multiple safety protocols. Non-rebreather masks require a doctor's order and high-flow oxygen delivery systems that weren't available in resident rooms. The facility's own policy stated these masks should deliver 10-15 liters per minute and maintain the reservoir bag at least one-third to one-half full during inspiration.
Room oxygen concentrators couldn't provide the high flow rates needed for safe non-rebreather use.
APRN 1 told inspectors on December 30 that staff were expected to follow orders exactly as written. She said non-rebreather masks required both a doctor's order and high-flow oxygen systems unavailable on room concentrators.
The medical director reinforced this expectation during her interview the same day. She said Resident 42 should have been receiving humidified oxygen if that's what the doctor ordered. The medical director emphasized that non-rebreathers shouldn't be used with low-flow oxygen and would require a separate physician order to change from the prescribed nasal cannula delivery method.
Despite clear protocols, three staff members responsible for Resident 42's care had never received the facility's respiratory training for 2025. The licensed practical nurse and both nursing assistants assigned to the resident missed the education sessions that covered proper oxygen equipment use.
The training materials explicitly stated that non-rebreather masks should only be used with provider orders and high-flow oxygen systems. The facility had provided appropriate respiratory education, but the staff caring for Resident 42 hadn't attended.
Facility policy defined non-rebreather masks as emergency equipment designed for short-term use in urgent situations. The policy specified these masks delivered oxygen through both nose and mouth, requiring physician orders and flow rates that maintained proper reservoir bag inflation.
The oxygen delivery error represented a fundamental breakdown in following medical orders. Resident 42's doctor had prescribed a specific delivery method - humidified oxygen through nasal cannula. Staff substituted different equipment that required different medical authorization and equipment capabilities not present in the resident's room.
The violation occurred despite the facility having written policies that clearly outlined when and how different oxygen delivery systems should be used. The respiratory training materials covered the same safety requirements that staff ignored when caring for Resident 42.
APRN 1's interview revealed the expectation that staff notify physicians about any concerns or needed changes to medical orders. Instead of seeking proper authorization for equipment changes, staff made the switch independently.
The medical director's comments highlighted the safety implications of using inappropriate oxygen delivery methods. Non-rebreather masks with low-flow oxygen could compromise patient safety, which is why they required specific physician orders and high-flow delivery systems.
The facility's own policy acknowledged that non-rebreather masks were designed for emergent situations and short-term use only. Resident 42's case involved neither emergency conditions nor temporary oxygen needs that would justify the equipment substitution.
The training gap meant the three staff members most directly responsible for Resident 42's respiratory care lacked current knowledge about proper oxygen equipment selection and safety requirements. This educational deficit contributed directly to the violation of medical orders and safety protocols.
The case demonstrated how individual staff training failures could compromise resident safety even when facilities maintained appropriate policies and educational programs. The disconnect between available training and actual staff participation left Resident 42 receiving inappropriate oxygen therapy that violated both medical orders and safety standards.
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.