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F0684
D

Oxygen Therapy Administered Without Physician Order

Lancaster, California Survey Completed on 08-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received care consistent with professional standards of practice by administering oxygen therapy without a physician's order. The resident, who had diagnoses including Parkinson's Disease, difficulty walking, and shortness of breath, was observed to have been on daily oxygen for several days following readmission from an acute care hospital. Review of the resident's records, including the admission record, history and physical, and physician orders, confirmed that there was no physician order for oxygen use during this period. The care plan referenced giving medications as ordered by the physician, but no specific order for oxygen was present. Multiple staff interviews confirmed that oxygen was administered to the resident without a physician's order, and staff acknowledged that such an order is required for oxygen therapy. The facility's policy and procedure also specified that medications and treatments, including oxygen, must be administered only upon a written physician order. The Director of Nursing confirmed that the nurses failed to obtain the necessary order and that oxygen is considered a medication requiring a physician's authorization before use.

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