Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including heart failure, atherosclerotic heart disease, and anemia was observed multiple times with oxygen tubing and an oxygen concentrator in their room, but without a physician's order for oxygen therapy. The resident reported self-administering oxygen as needed when experiencing shortness of breath, and stated that the oxygen machine was already set to 4 liters. Despite these observations, there was no documentation of a physician's order for oxygen in the resident's medical record. The Assistant Director of Nursing confirmed unawareness of the resident's use of oxygen and acknowledged that a physician's order is required for PRN oxygen use. Facility policy also specifies that oxygen must be administered under a physician's order except in emergencies, with orders to be obtained as soon as practicable. The lack of a physician's order for the resident's ongoing use of oxygen therapy was inconsistent with professional standards of practice and facility policy.