Oxygen Therapy Provided Without Physician Order
Penalty
Summary
A deficiency was identified when a resident was observed receiving oxygen therapy via nasal cannula at a flow rate of 2.0 liters per minute on two separate occasions. Review of the resident's clinical record revealed there was no physician order for oxygen or respiratory care documented. During an interview, the Director of Nursing confirmed that the resident did not have an order for oxygen use. This failure to ensure respiratory care was provided in accordance with professional standards and without a proper order led to the cited deficiency.
Plan Of Correction
R1's orders were updated to reflect the use of oxygen therapy. Residents requiring oxygen therapy had their orders reviewed for oxygen use. Education will be completed by DON/designee with all licensed staff to ensure physician orders are placed when oxygen therapy is ordered. The DON/designee will review 5 residents per week for 4 weeks then monthly for 2 months to ensure residents with oxygen therapy have physician orders entered. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.