Failure to Transcribe Physician Orders and Obtain Required Orders for Oxygen Therapy
Penalty
Summary
Staff failed to ensure that services provided met professional standards of care in two separate instances. For one resident with a history of urinary tract infections (UTIs), a physician ordered a urine analysis (UA) and culture and sensitivity (C/S) test after the resident complained of pelvic pain and dysuria. However, the order was not transcribed into the computer system, and there was no documentation that the urine was collected or that the physician was notified of any results. The resident's care plan indicated ongoing antibiotic therapy and monitoring for UTIs, but the required diagnostic tests were not obtained as ordered. In a second instance, another resident who was cognitively intact and had diagnoses including chronic lung disease was observed receiving continuous oxygen therapy via nasal cannula at varying flow rates. Despite this, there was no physician order for oxygen therapy in the resident's medical record. Progress notes documented multiple episodes where the resident experienced respiratory distress and received oxygen, but staff confirmed that no physician order was present for this intervention. Both the LPN and DON acknowledged that a physician order should have been in place for the oxygen therapy.