Failure to Ensure Physician Order and Proper Functioning of Oxygen Therapy
Penalty
Summary
A resident with a history of dependence on supplemental oxygen, heart failure, and atrial fibrillation was admitted to the facility. During observation, the resident was found in bed with a nasal cannula in place, but the oxygen concentrator was turned off. When staff were notified, the Assistant Director of Nursing attempted to turn on the concentrator, which began to beep and was not functioning properly. The concentrator was then replaced with a new one. The Assistant Director of Nursing stated she had not been previously informed of any issues with the concentrator. Further review revealed that there was no current physician order for the resident's oxygen use. The last order for oxygen had been discontinued when the resident was hospitalized, and was not renewed upon readmission, despite the ongoing need for supplemental oxygen. The facility's policy requires a physician order for oxygen therapy, including specific details such as liter flow and delivery device, and mandates equipment checks and proper setup prior to administration. These requirements were not followed, resulting in the deficiency.