Failure to Obtain Physician Order and Document Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including COPD, chronic respiratory failure, and dependence on supplemental oxygen, was observed receiving oxygen therapy at a flow rate of 3.5 L/min via nasal cannula connected to an oxygen concentrator. Despite the ongoing administration of oxygen, there was no physician's order for oxygen therapy or for the care and maintenance of the oxygen delivery devices documented in the resident's medical record from admission through the time of the survey. Further review of the resident's medication administration record (MAR) and treatment administration record (TAR) for the relevant month revealed no evidence that oxygen therapy or care of the oxygen delivery devices was documented as provided or received. The resident's care plan did include interventions related to respiratory management, such as administering oxygen as ordered and monitoring respiratory status, but these interventions were not supported by corresponding physician orders or documentation of implementation. Interviews with nursing staff and the Assistant Director of Nursing confirmed that there was no physician's order for oxygen therapy or for the care of the oxygen equipment in the electronic medical record. Staff also acknowledged that administration of oxygen and related care should be documented on the MAR, but this was not found for the resident in question. Facility policy required a physician order for oxygen therapy, ongoing assessment, and documentation, none of which were present for this resident.