Failure to Obtain Physician's Order for Supplemental Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for supplemental oxygen use for one resident who was admitted with multiple respiratory diagnoses, including pulmonary embolism, acute respiratory failure with hypoxia, atelectasis, pulmonary fibrosis, and pulmonary hypertension. The facility's standard operating procedure required verification of a physician's order prior to administering oxygen. Despite this, the resident was provided with supplemental oxygen nightly since admission, as documented in nursing progress notes and confirmed by staff interviews. The care plan directed staff to administer oxygen per physician's order, but no specific order for oxygen administration or flow rate was found in the resident's active orders. Multiple staff members, including LPNs and the Director of Health Services, acknowledged that a physician's order was necessary for supplemental oxygen administration and confirmed that the resident had been using oxygen at night without such an order. Nursing and physician progress notes referenced the resident's use of oxygen, but did not specify the required parameters or provide a formal order. The deficiency was identified through interviews, record reviews, and review of facility procedures, all of which confirmed the lack of a required physician's order for the ongoing administration of supplemental oxygen to the resident.