Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by administering oxygen therapy to a resident without a physician's order. According to the facility's own policy, a physician's order specifying the liter flow and method of administration is required before oxygen therapy can be provided. Review of the resident's clinical record showed no physician's order for oxygen therapy, despite the resident having diagnoses including acute respiratory failure with hypoxia, emphysema, and unspecified heart failure. Observations confirmed that an oxygen concentrator was present and in use in the resident's room, set at 2 liters per minute. Interviews with nursing staff verified that the resident had been using oxygen as needed, including the night prior to the survey, without a physician's order. The Director of Nursing also confirmed the absence of an order for oxygen therapy in the resident's clinical record, acknowledging that such an order was required before administration.