Failure to Obtain Physician Orders for Oxygen and OTC Medications
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents by not obtaining physician orders prior to administering oxygen therapy and allowing over-the-counter (OTC) medications to be present and self-administered without proper authorization. For one resident, oxygen tubing and a saline humidifier were observed in the room, and the resident reported using oxygen as needed, despite no physician order or care plan documentation for oxygen use. Staff interviews confirmed that the oxygen equipment should not have been available without a physician's order, and that the resident sometimes used oxygen at their discretion. For another resident, several OTC medications, including bacitracin zinc ointment, Bigeloil topical pain gel, and lidocaine ointment, were found in the resident's room without corresponding physician orders or documentation permitting self-administration. The care plan did not address self-administration of these medications, and the Assistant Director of Nursing confirmed that all medications, including OTC, require a physician order. The family had brought in the OTC medications, but there was no evidence of physician oversight or authorization for their use.