Oxygen Administered Without Physician Order
Penalty
Summary
Nursing staff failed to obtain a physician's order for oxygen administration for a resident who had been maintained on oxygen via nasal cannula during a recent hospital stay for RSV with pneumonia, new onset seizures, and a nasal gastrostomy tube. Upon admission to the facility, the resident's hospital discharge summary indicated stability on room air, but the admission nursing assessment noted continued use of oxygen via nasal cannula, though without specifying the liter flow. Despite this, there was no physician's order documented for oxygen administration or for the specific liter flow in the resident's medication or treatment administration records. Nursing progress notes documented that the resident was receiving oxygen at 2 liters via nasal cannula, and a nurse practitioner note instructed to titrate oxygen as appropriate. Interviews with facility staff, including the Unit Manager, ADON, and DON, confirmed that the expectation is for all medications and treatments, including oxygen, to have a physician's order upon admission. However, staff were unaware that an order for oxygen had not been obtained, resulting in the administration of oxygen without the required physician authorization.