Oxygen Therapy Administered Without Physician Order
Penalty
Summary
Licensed nursing staff failed to ensure that a physician's order was in place for a resident's oxygen use. During observation, a resident with a diagnosis of metastatic lung cancer was found lying in bed using oxygen via nasal cannula, with the concentrator set to 1.5 liters. The resident reported using oxygen continuously due to his terminal condition. Staff interviews confirmed that nursing staff are responsible for obtaining physician orders for oxygen therapy and are expected to notify the physician and secure the necessary order when oxygen is needed. However, a review of the resident's physician orders for the relevant period showed no order for oxygen use, despite facility policy requiring a provider order for initiation of oxygen therapy.