Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of COPD who was receiving oxygen therapy had a corresponding physician's order in her medical record. The resident was observed on multiple occasions using oxygen via nasal cannula, with the oxygen concentrator set at 2 liters per minute. The resident reported wearing oxygen at all times due to her COPD. Review of the resident's care plan indicated she was to receive oxygen therapy, but it did not specify the number of liters to be administered. Additionally, the physician order summary did not contain an order for oxygen, and the admission MDS had not yet been completed. Interviews with nursing staff and facility administration revealed that the lack of an oxygen order was not identified until brought to their attention by the surveyor. The charge nurse responsible for the resident's care and the regional compliance nurse both confirmed that an order should have been present in the electronic medical record. The facility's policy on oxygen administration requires a physician's order specifying the amount and method of oxygen delivery, which was not followed in this case.