Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who was observed receiving oxygen therapy without a physician's order. During an observation, the resident was found to be receiving oxygen at 3.5 L/min via nasal cannula, but a review of the medical record revealed no active physician's order for oxygen therapy. The resident had a history of heart failure, COPD, and both acute and chronic respiratory failure with hypoxia. The care plan indicated that oxygen should be administered as ordered, but this was not followed, as there was no documented order in place. Interviews with staff revealed that CNAs were not responsible for changing oxygen flow rates and would notify a nurse if issues arose, while LPNs stated they would adjust oxygen based on physician orders. However, the LPN confirmed that the resident used oxygen daily without an order. Additionally, the facility did not have a specific policy for oxygen administration, and the procedural guideline for physician's orders required detailed documentation, which was not present for this resident's oxygen therapy.