Resident 42 was supposed to receive humidified oxygen through a nasal cannula. Instead, nursing staff provided a non-rebreather mask with unhumidified oxygen from a low-flow concentrator in the resident's room.
The equipment switch violated multiple safety protocols. Non-rebreather masks require high-flow oxygen systems that deliver 10 to 15 liters per minute, not the low-flow concentrators available in patient rooms. The masks are designed for emergency situations and short-term use only.
"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's medical director told inspectors on December 30.
The medical director said she expected oxygen to be administered exactly as doctors ordered. Resident 42 should have been receiving humidified oxygen if that was specified in the prescription.
An advanced practice registered nurse confirmed that staff were expected to follow orders precisely and notify physicians if changes were needed. The APRN noted that non-rebreather masks require doctor's orders and high-flow oxygen systems not available through room concentrators.
The facility's own respiratory training materials from 2025 specified that non-rebreathers should only be used with provider orders and high-flow oxygen. The training emphasized that oxygen flow rates should maintain the mask's reservoir bag at least one-third to one-half full during inspiration.
None of the staff caring for Resident 42 had received this training.
The licensed practical nurse and both nursing assistants responsible for the resident's care missed the facility's respiratory education sessions. They administered oxygen using equipment they weren't trained to operate safely.
Facility policy clearly outlined the purpose and proper use of non-rebreather masks. The equipment was designed to deliver high-flow oxygen through both nose and mouth, per physician orders. Policy specified the masks were generally used for emergent situations and only for short periods.
The policy violations created multiple safety risks. Non-rebreather masks used with inadequate oxygen flow can cause carbon dioxide retention and inadequate oxygen delivery. Low-flow systems cannot maintain proper reservoir bag pressure, potentially compromising the resident's breathing.
Unhumidified oxygen presents additional concerns. Extended exposure to dry oxygen can irritate respiratory passages and cause discomfort, particularly for residents requiring continuous oxygen therapy.
The inspection found that despite providing appropriate respiratory education materials, the facility failed to ensure that staff actually caring for oxygen-dependent residents received the training. The gap between policy and practice left Resident 42 receiving improper treatment.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the incident highlighted systemic problems with staff training and supervision of medical equipment use.
The medical director's comments during the inspection suggested she was unaware that her facility's staff were routinely substituting equipment without physician orders. Her expectation that oxygen be administered "as ordered by the doctor" contrasted sharply with what inspectors observed in Resident 42's care.
The case illustrates how seemingly minor equipment substitutions can compromise resident safety. What staff may have viewed as a simple mask change actually violated multiple medical protocols and potentially endangered the resident's respiratory health.
Resident 42's experience reflects broader concerns about medication and treatment administration in nursing facilities. When staff lack proper training on the equipment they're using daily, residents face unnecessary risks that proper oversight could prevent.
The facility now faces questions about how many other residents may have received improper oxygen therapy and whether current training requirements adequately prepare staff for the medical responsibilities they shoulder.
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.