Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with a history of chronic respiratory failure with hypoxia and pleural effusion was readmitted to the facility following a hospital transfer. Upon review of the clinical record, it was found that the resident previously had a physician's order for oxygen therapy via trach collar at 4 liters per minute, which was discontinued when the resident was transferred to the hospital. After the resident's return, there was no new physician's order for oxygen therapy documented in the medical record. Despite the absence of a current physician's order, observations on two separate occasions confirmed that the resident was receiving oxygen via concentrator at 3.5 liters per minute. Interviews with the unit manager and a licensed nurse confirmed that the resident was receiving oxygen without a physician's order, and that the previous order had been discontinued upon hospital transfer. The care plan for the resident continued to reference oxygen therapy, but no corresponding physician's order was present in the record at the time of the observations.