Failure to Obtain Physician Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that two residents who were receiving supplemental oxygen had active physician orders for this therapy. Both residents had significant medical histories, including chronic obstructive pulmonary disease, morbid obesity, anemia, congestive heart failure, malignant neoplasms, and muscle wasting. During the investigation, one resident was observed receiving oxygen via nasal cannula, and both residents confirmed ongoing use of supplemental oxygen. However, review of their medical records and order summaries revealed no active physician orders for oxygen for either resident. Nursing staff, including an LPN and the Director of Nursing, confirmed the absence of these orders and acknowledged that physician authorization is required for oxygen administration. The facility's own oxygen report listed both residents as receiving supplemental oxygen, yet their order summaries did not reflect any such orders. The facility's policies require that physician orders be transcribed and implemented according to professional standards and that necessary information for immediate care, including oxygen therapy, be provided at or before admission. Despite these policies, the lack of active physician orders for oxygen was not identified or addressed prior to the surveyor's investigation.