Avoiding Survey Deficiencies: Writing Clear Oxygen Orders in Skilled Nursing Facilities

When it comes to oxygen orders in skilled nursing facilities, the details matter—a lot. If you’re a clinician, you know there are multiple ways to write an order for oxygen delivery. However, not all methods are created equal in the eyes of surveyors. Recently, I’ve noticed two common approaches to oxygen orders that, while clinically sound, could unintentionally lead to deficiencies on a survey. Here’s a closer look and some practical advice to help you avoid these issues.

1. The “Up To” Order: Adjusting Oxygen Flow Based on Saturation Levels

One approach we often see is writing an order for oxygen “up to” a certain liters per minute to maintain an SpO? (oxygen saturation) of, say, 92% or above. The flexibility here allows the team to adjust the oxygen flow as needed to keep the patient within a safe range. However, there’s a potential snag.

In some states, LPNs aren’t permitted to assess and adjust oxygen flow based on SpO? readings. If they’re the ones primarily checking patients' oxygen saturation, this “up to” approach could be seen as outside their scope of practice, creating a deficiency risk during a survey. The order might sound straightforward, but if the staff can’t make the necessary adjustments, it’s a compliance issue waiting to happen.

2. FiO? Orders Instead of LPM: Conversion Confusion

Another approach that can cause issues is specifying oxygen as a fraction of inspired oxygen (FiO?) percentage rather than in liters per minute. FiO? is commonly used in hospitals or acute care settings and can be a more precise measure of oxygen delivery. However, this can be problematic in SNFs, where surveyors might expect FiO? orders to be supported by actual oxygen analysis.

While there are FiO? to LPM conversion charts to guide oxygen delivery, some surveyors could question whether the facility is equipped to measure and verify FiO? accurately. Unless you’re actually analyzing the oxygen concentration, the order may be seen as incomplete or even misleading.

Our Advice: Stick with Specific LPM Orders

At NJRA, we believe both of these methods are valid and, in many cases, preferred. But we also recognize that survey expectations can sometimes feel like an obstacle course. To keep things simple and survey-friendly, we recommend writing oxygen orders as a specific LPM. This approach provides clarity, avoids potential scope-of-practice issues for staff, and reduces the chance of deficiencies tied to what we see as overly stringent expectations.

Bottom Line: Clear, Simple Orders Lead to Compliance Success

In the world of skilled nursing, clear and specific orders can make a world of difference in compliance. By setting your oxygen orders at a precise LPM, you can help your facility stay survey-ready and avoid unnecessary deficiencies. It’s a small step that ensures your patient care standards align with surveyor expectations—keeping everyone breathing easier.