Failure to Obtain Physician Orders and Label Oxygen Tubing for Respiratory Care
Penalty
Summary
The facility failed to implement its own policy and procedure for oxygen administration by not obtaining a physician's order prior to administering oxygen to two residents. In the case of one resident with a history of COPD, major depressive disorder, and respiratory failure, the resident had previously received continuous oxygen therapy as ordered by a physician. However, after the physician's order for oxygen was discontinued following a hospitalization, staff continued to provide oxygen without a current physician's order. This was confirmed through interviews and record reviews, where both the LVN and DON acknowledged the absence of a valid order and the ongoing administration of oxygen. For another resident with a history of amputation, osteomyelitis, diabetes, asthma, and sleep apnea, oxygen was administered for shortness of breath without a physician's order. The resident's care plan indicated a risk for respiratory complications and included interventions for oxygen therapy as ordered, but no current physician order was found in the records. Staff confirmed that oxygen had been given and that the tubing and nasal cannula used for oxygen delivery were not labeled with the date they were last changed, as required by facility policy. Observations revealed that the oxygen tubing for this resident remained in the room and was not labeled, and staff interviews confirmed that the tubing had not been changed or labeled according to protocol. The facility's policy required verification of a physician's order before oxygen administration and mandated that oxygen tubing be labeled with the date of the last change to prevent infection. These requirements were not followed in both cases, as confirmed by staff and record review.