Oxygen Administered Without Physician Order
Penalty
Summary
A resident with a history of acute and chronic respiratory failure with hypoxia was observed receiving oxygen via nasal cannula at 3 liters per minute while in bed and awake. Review of the clinical record revealed that there was no physician's order for oxygen administration at the time of observation. Staff interviews confirmed that the resident had been on oxygen since being decannulated and experiencing desaturation, but no physician's order had been obtained for the oxygen therapy provided. Further interviews with the respiratory therapist confirmed that the resident was placed on 3 liters of oxygen without a physician's order, and that the physician was only later asked to write an order, which was for 2 liters per minute. The facility's policy requires verification of a physician's order prior to oxygen administration, but this protocol was not followed for this resident.