Failure to Ensure Physician Orders and Care Plan for Oxygen Therapy
Penalty
Summary
A resident with diagnoses including hypertension, end stage renal disease, and type 2 diabetes mellitus was observed on two occasions using oxygen via nasal cannula at a flow rate of 1.5 liters, while the resident reported it was usually set at 2 liters. Review of the resident's medical record revealed no current physician's order for oxygen therapy and no care plan addressing oxygen use. The Admission MDS assessment indicated the resident was moderately cognitively impaired and did not receive oxygen therapy. The facility's policy required that residents on oxygen have physician orders specifying the route and liter flow, but no such orders were found in the resident's chart. The DON confirmed the absence of current oxygen orders for the resident.