Oxygen Administered Without Physician Order
Penalty
Summary
A resident with a diagnosis of chronic obstructive pulmonary disease (COPD) was administered supplemental oxygen without a current physician's order. The resident's admission and assessment records indicated a need for supervision and assistance with daily activities, but there was no active order for oxygen administration after the previous order was discontinued. Despite this, the resident reported using 2 liters per minute of oxygen daily as needed, and nursing staff provided oxygen upon the resident's request. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that a physician's order is required for oxygen administration, specifying the amount and monitoring parameters. The facility's policy also mandates verification of a physician's order before administering oxygen. However, documentation and staff statements revealed that oxygen was given to the resident without such an order, and oxygen saturation was only documented twice after the order was discontinued.