Oxygen Therapy Administered Without Physician Orders
Penalty
Summary
The facility failed to obtain physician orders for oxygen therapy for two residents who were receiving oxygen. Both residents had been admitted with medical conditions that included acute kidney failure, sleep apnea, asthma, acute respiratory failure, chronic obstructive pulmonary disease, and sepsis. Medical record reviews showed that both residents had intact cognition and varying levels of independence in daily activities. Despite this, both were observed to be on 2 liters of oxygen via nasal cannula. Further review revealed that neither resident was listed on the facility's oxygen tubing list, and interviews with both residents confirmed they had been receiving oxygen since admission. The DON confirmed that the residents were receiving oxygen without a physician's order, which was not in accordance with the facility's policy that requires a physician's order for oxygen administration except in emergencies. The deficiency was identified during a complaint investigation.