Failure to Maintain Physician's Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure a physician's order for oxygen was in place for a resident with a history of respiratory failure, hypertension, and diabetes mellitus. The resident's care plan and quarterly MDS assessment indicated ongoing oxygen therapy, and observations confirmed the resident was using oxygen via nasal cannula. However, review of the physician's orders revealed that after a certain date, there was no active order for oxygen therapy, only an order for routine tubing changes. Nursing notes indicated that the nurse practitioner discontinued daily oxygen saturation checks and changed monitoring to monthly, but the oxygen order itself was inadvertently discontinued at the same time. Further observations showed the resident wearing a nasal cannula, with the oxygen concentrator sometimes turned off, which was verified by the DON, who acknowledged the resident would turn off the oxygen at times. The DON also confirmed that the oxygen order should have remained in place and that its discontinuation was an error linked to the change in monitoring frequency. Facility policy required a physician's order for oxygen administration, which was not maintained in this case.