Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for a resident who was admitted with intermittent oxygen use. Review of the resident's medical record showed that while there were orders for changing oxygen tubing, conducting a 6-minute rest/walk test on room air, and monitoring pulse oximetry every shift, there was no physician's order for the actual administration of oxygen. Additionally, the resident's care plan did not reflect that the resident was receiving oxygen. Interviews with facility staff, including the social worker, LPN, unit manager, DON, and ADON, confirmed that the resident used oxygen intermittently and that there was no corresponding physician's order or care plan entry for oxygen administration during the period it was used. Facility policy requires verification of a physician's order prior to oxygen administration and review of the care plan for any special needs related to oxygen use. Staff interviews further revealed that the expectation was to ensure a physician's order was in place for any resident receiving oxygen and to update or discontinue the order as appropriate. The absence of a physician's order and care plan documentation for oxygen use was acknowledged by the DON and ADON, confirming the deficiency in following professional standards and facility policy.