Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident with chronic respiratory failure. The resident, who had moderate cognitive impairment and required assistance for care needs, was observed receiving oxygen therapy at four liters per minute on multiple occasions. Despite the care plan indicating the necessity of oxygen therapy, there was no documented evidence in the clinical records that a physician's order had been obtained for this treatment. This deficiency was confirmed through an interview with the Director of Nursing, who acknowledged the lack of documentation for the physician's order.
Plan Of Correction
1. An order for oxygen was obtained for resident 5. 2. The Interdisciplinary team will review progress notes and orders during the morning clinical meeting to determine if the oxygen orders were obtained on those residents that are using oxygen. An audit was completed 12/29 to make sure those residents using oxygen have physician orders. 3. Licensed Nursing staff educated on the process of monitoring those residents on oxygen have physician orders in the electronic record. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks, then monthly for two months on residents' rounds to make sure residents on oxygen have appropriate orders. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.