Oxygen Therapy Administered Without Active Physician Order
Penalty
Summary
The facility failed to ensure that a resident received safe and appropriate respiratory care by administering continuous oxygen therapy without an active physician's order. Record review showed that the resident was admitted with intellectual disabilities and had a care plan indicating continuous oxygen therapy. However, there was no current physician order for oxygen administration in the electronic medical record. Observations over several days confirmed that the resident was receiving oxygen at two liters per minute via nasal cannula. Interviews with staff revealed that an LPN believed there was an active order for continuous oxygen, but had not checked the order recently. The nurse practitioner confirmed that the order for oxygen had been discontinued and was unaware that the resident was still receiving oxygen. The DON stated that staff are expected to verify physician orders each time they assess a resident and to discontinue treatments when orders are discontinued. Despite these expectations, the resident continued to receive oxygen therapy without a valid order.