Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis was administered continuous oxygen therapy without a physician's order in place, as required by the facility's Oxygen Management Policy. The resident was observed receiving oxygen on two separate occasions, and review of the electronic health record confirmed that no physician's order for oxygen existed prior to a specific date. Staff interviews further confirmed that the resident had been using oxygen since admission, but the order was not entered until several days later. The facility's policy, revised in December 2022, mandates that a physician's order must be obtained before administering oxygen. Despite this, staff acknowledged that the resident was admitted with oxygen and continued to receive it without the necessary order. The Director of Nursing Services also confirmed that oxygen administration should follow facility policy, which was not adhered to in this instance.