Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and sleep apnea was provided with oxygen therapy without an active physician's order. The resident's care plan indicated the need for oxygen as ordered, and multiple clinical records, including vital summaries and progress notes, documented the use of oxygen via nasal cannula on several occasions. During interviews, both the licensed nurse and the Director of Staff Development confirmed that oxygen was administered to the resident when she experienced difficulty breathing, despite the absence of a current physician's order for this treatment. Facility policy and procedures for oxygen administration require verification of a physician's order prior to providing oxygen therapy. Both the Director of Staff Development and the Director of Nursing stated that an active physician's order is necessary to safely administer oxygen to residents. The failure to obtain and verify a physician's order before administering oxygen resulted in the delivery of respiratory care that was not consistent with facility policy and standard practice.