Oxygen Therapy Provided Without Physician Order
Penalty
Summary
A resident with diagnoses including congestive heart failure and chronic obstructive pulmonary disease (COPD) was observed with an oxygen concentrator at the bedside and reported using oxygen at bedtime. Multiple observations confirmed the ongoing presence of the oxygen equipment in the resident's room. Review of the clinical record and order summary revealed that there was no physician's order for oxygen therapy for this resident at the time of the observations. The resident's care plan identified a risk for shortness of breath and included an intervention to administer oxygen per physician's order. However, the DON confirmed that the oxygen may have been initiated as a nursing measure during a CHF flare-up and was not discontinued or removed when no longer needed. Facility policy required that oxygen be administered only under a physician's order, which was not followed in this case.