Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen therapy for a resident with diagnoses including COPD with exacerbation, acute respiratory failure, and dementia. The resident was observed receiving oxygen via nasal cannula at varying flow rates without a humidifier, and there was no documented physician order specifying the use, flow rate, or care instructions for the oxygen therapy. Medical records did not contain evidence of an order for oxygen or for changing the nasal cannula, despite the resident's continuous dependence on supplemental oxygen. Interviews with nursing staff and the Director of Nursing confirmed that no physician order was in place for the oxygen therapy or related care, and that staff were expected to obtain such orders at the onset of oxygen use. The Physician Assistant also confirmed that a physician's order specifying flow rate, delivery method, and monitoring parameters was required for supplemental oxygen. Facility policies reviewed indicated that a physician's order was necessary for oxygen administration and for all medications and treatments.