Failure to Obtain Physician Order and Post Oxygen Warning Sign for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen therapy and did not post an oxygen warning sign for a resident who required respiratory care. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, cerebral infarction, and atherosclerosis, and was assessed as needing substantial assistance with daily activities. The care plan indicated that oxygen should be provided as needed when the resident exhibited signs of difficulty breathing, but there was no active physician order for oxygen therapy in the resident's medical record. Observations on two separate days revealed that the resident was using an oxygen concentrator set to 2 liters, with a nasal cannula either on the bed or in use, but there was no oxygen in use sign displayed on the resident's door. Interviews with nursing staff confirmed the absence of both the required physician order and the oxygen warning sign. Review of the facility's policy on oxygen administration indicated that both a physician's order and an oxygen warning sign are required when oxygen is in use.