Oxygen Therapy Administered Without Timely Physician Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen was admitted and administered continuous oxygen therapy without a physician's order. Nursing documentation indicated that the resident was receiving oxygen at varying flow rates, including 6 to 7 liters at rest and up to 10 liters with ambulation, starting from the time of admission. The care plan and care card referenced the need for oxygen and specific interventions, but there was no documented physician's order for oxygen administration until eight days after the resident began receiving it. Facility policy required that only licensed staff administer oxygen as prescribed by a physician, and interviews confirmed that a physician's order should have been obtained at the time of admission. The Director of Nursing acknowledged that the order was missing and was only obtained after reviewing the clinical record several days later. This lapse resulted in the resident receiving oxygen therapy without the necessary physician authorization, contrary to facility policy and standard practice.