Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the provision of oxygen therapy for a resident with chronic obstructive pulmonary disease (COPD), dementia, and high blood pressure. The resident was observed using an oxygen nasal cannula connected to an oxygen concentrator delivering 2 liters per minute on multiple occasions. The clinical records indicated the resident utilized oxygen on several dates, but there was no evidence of a physician's order for this therapy. A Licensed Practical Nurse confirmed the absence of a physician's order during an interview.
Plan Of Correction
1. Obtained an order for oxygen for resident #26. Oxygen at 2 liter as needed. Responsible party was notified of order. 2. Current residents that are using oxygen were reviewed to determine they had orders for oxygen therapy in electronic medical record. 3. Director of Nursing or designee educated License staff on the respiratory policy. Nurses educated that residents must have an order for oxygen therapy. 4. Director of Nursing or designee will audit all residents to ensure that residents using oxygen therapy have orders for oxygen in electronic medical record. Audits will be completed 3 x weekly for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meeting monthly until compliance is met.