Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that physician's orders were obtained for oxygen therapy for one resident. During an initial tour, it was observed that the resident was using a nasal cannula connected to an oxygen concentrator at 4 liters per minute. The resident confirmed that she had been on oxygen since a recent hospitalization. Subsequent observations confirmed the continued use of oxygen at the same rate. A review of the resident's medical record revealed no physician's order for the oxygen therapy. The Director of Nursing confirmed that the resident returned from an emergency room visit on continuous oxygen, as noted in the hospital discharge summary, but the nurse had not obtained a physician's order for the therapy.
Plan Of Correction
Education provided to all licensed nurses regarding Policy #1901- Respiratory Care and Oxygen Equipment. Nurse Managers will conduct Oxygen Order Audit weekly times four weeks, then biweekly times two months, then monthly times three months to ensure that all residents receiving Oxygen have appropriate physician orders per policy. All data will be reported at QAPI. Other residents who potentially could be affected by not having an order in place will be identified through the audit. R45 had a physician's order put into place immediately on discovering that her readmission orders did not have her previous O2 order in place.