Failure to Obtain Physician's Order and Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that a physician's order was present for the administration of oxygen and by not developing a care plan for its use. Observations on two consecutive days showed the resident receiving oxygen via nasal cannula at 1 L/min, but a review of the medical record revealed no physician's order authorizing this treatment. Additionally, the resident's care plan did not address the use of oxygen, despite facility policy requiring verification of a physician's order and care plan review prior to administration. The resident involved had diagnoses including asthma, anxiety, and malnutrition, and was assessed as having moderately impaired cognition, requiring partial to maximal assistance with activities of daily living. Interviews with nursing staff and the Director of Nursing confirmed that both a physician's order and a care plan should have been in place for the use of oxygen, but neither was found in the resident's records.