Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
Facility staff failed to provide appropriate respiratory care for one resident by not obtaining a physician's order for oxygen therapy prior to administration. The resident was admitted with diagnoses including respiratory failure and was assessed as cognitively intact. During an observation, the resident was found to be receiving oxygen at three liters per minute via nasal cannula. At the time of the observation, there was no documented physician's order for the oxygen therapy being administered. The physician's order for continuous oxygen at three liters per minute by nasal cannula was only created later that same day, after the resident had already been observed receiving oxygen. This lapse was confirmed by the unit manager, who acknowledged that no order was present at the time of the surveyor's observation.