Failure to Obtain Physician Order and Update Care Plan for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident who had a tracheotomy tube removed was subsequently placed on supplemental oxygen via nasal cannula without a physician's order specifying the oxygen administration details. The facility's policy requires a physician's order for oxygen administration, including specifics such as flow rate, delivery method, and parameters for use. However, after the resident's decannulation, no new order was obtained for the oxygen therapy provided, and the care plan was not updated to reflect the change in respiratory support. The resident had a complex medical history, including acute and chronic respiratory failure, COPD, asthma, and a tracheostomy. Documentation showed that the resident was receiving 3 liters of oxygen via nasal cannula following the removal of the tracheostomy tube, but there was no corresponding physician order or individualized care plan update specifying the method, amount, or frequency of oxygen delivery. Progress notes and staff interviews confirmed that oxygen was administered and documented, but the required medical order and care plan details were missing during the resident's stay after decannulation. Interviews with nursing staff, including LPNs, RNs, and the DON, revealed a consensus that a physician's order is necessary for oxygen administration and that the care plan should include specific details about oxygen therapy. Despite this, the facility failed to obtain the required order and did not update the care plan to reflect the resident's new oxygen needs, resulting in a lack of compliance with facility policy and regulatory requirements.