Failure to Obtain Provider Order for Supplemental Oxygen Administration
Penalty
Summary
A resident with diagnoses including chronic kidney disease and heart failure was found to have received supplemental oxygen therapy on multiple occasions over a period of several months without a corresponding provider order or care plan documentation. The resident's medical records, including the provider order list and care plan, lacked any information regarding the use or monitoring of supplemental oxygen, despite documentation showing the resident used oxygen via nasal cannula on numerous days in May, June, and July. Nursing notes and provider visit notes repeatedly referenced the resident's use of oxygen at varying flow rates, but none of these notes included an official order for oxygen therapy. Interviews with facility staff, including an LPN, RN, nurse practitioner, and the DON, confirmed that the resident had been receiving supplemental oxygen without a provider order prior to a specific date in July. The facility's own policy required a physician's order for oxygen administration, which was not followed in this case. Observations on the day of the survey confirmed the resident was using oxygen, and staff acknowledged the absence of a provider order for this therapy.