Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of asthma, acute and chronic respiratory failure, sleep apnea, and COPD was observed receiving oxygen therapy via nasal cannula at 4 liters per minute from an oxygen concentrator. The resident reported using oxygen continuously and also using a BiPap machine. Review of the resident's records revealed that the physician's order for oxygen therapy had been discontinued several months prior, and there was no current order in place for oxygen administration. Additionally, the Medication Administration Record did not reflect ongoing oxygen therapy, nor was there documentation of ongoing assessment of the resident's respiratory status or response to the therapy. The resident's care plan referenced altered respiratory status and directed staff to use oxygen as ordered, but it lacked specific instructions regarding the type of delivery system, flow rates, timing, or monitoring requirements. Interviews with nursing staff and the Director of Nursing confirmed that it was the responsibility of the nurse to ensure physician orders were entered into the electronic health record (EHR) and that this had not been done for the resident's oxygen therapy. Facility policy required verification of a physician's order prior to administering oxygen, as well as documentation of the rate, route, and rationale, but these steps were not followed in this case.