Oxygen Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a newly admitted resident, who had diagnoses including a sacral fracture, muscle weakness, and difficulty walking, was administered oxygen without a physician's order. The resident was cognitively alert, had clear lungs, denied shortness of breath, and was not on oxygen at the time of admission. The care plan included interventions for cardiac risk, such as administering oxygen as ordered, but did not specify the need for oxygen at admission. On observation, the resident was found receiving oxygen at 2 liters per minute via nasal cannula, despite no documented physician's order in the clinical record or on the Medication/Treatment Administration Records. Interviews with nursing staff revealed that the LPN administering the oxygen was unaware of the reason for its use and confirmed that a physician's order was required but not present. The RN supervisor over the weekend had placed the resident on oxygen following an unexpected desaturation but failed to notify the provider or obtain an order. The facility's policy, as reviewed, required staff to verify and review a physician's order before administering oxygen, which was not followed in this instance.