Incomplete Oxygen Order and Unlicensed Administration
Penalty
Summary
A deficiency occurred when the facility failed to transcribe the complete physician order for oxygen administration for a resident with diagnoses including pneumonia, emphysema, and a stage II sacral pressure ulcer. The physician order sheet for the resident documented oxygen therapy but left the prescribed liter flow rate blank. During an observation, the resident was found in bed with a nasal cannula in place, but the oxygen concentrator was not turned on. The resident reported not receiving oxygen, prompting a certified nursing assistant (CNA) to turn on the concentrator and set the flow rate to two liters per minute. A registered nurse (RN) verbally confirmed the rate from across the bed after the CNA had already set it. The facility's policy requires that only licensed nurses administer oxygen and that physician orders specify details such as when to use, how often, the liter flow, and the delivery method. The administrator confirmed that the order should have included the oxygen rate and that only licensed nurses are permitted to administer oxygen, in accordance with facility policy and standard practice. The failure to transcribe the complete order and to ensure a licensed nurse administered the oxygen led to the deficiency.