Failure to Obtain Physician Order and Maintain Oxygen Therapy Equipment
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD), adult failure to thrive, and weakness had a physician's order for oxygen therapy and that oxygen supplies were properly maintained. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, was observed on multiple occasions receiving oxygen via nasal cannula at four liters per minute without a corresponding physician order in the medical record. Staff interviews confirmed that the resident was receiving continuous oxygen therapy without an order, and the Director of Nursing acknowledged that the resident had been on oxygen prior to hospice services being initiated, still without a physician's order. Additionally, observations revealed lapses in the maintenance of oxygen equipment. On one occasion, the oxygen tubing was found disconnected from the concentrator and lying on the floor while the concentrator was running. On another occasion, the humidifier bottle attached to the concentrator was empty, and the resident reported nasal dryness and soreness. Staff confirmed these findings and acknowledged that the humidifier bottle should not be allowed to run empty. Facility policy requires that oxygen be administered only under a physician's order, except in emergencies, and that equipment be properly maintained.