Failure to Reconcile Oxygen Therapy Orders on Admission
Penalty
Summary
The facility failed to ensure accurate reconciliation of medications on admission for a resident who was admitted with multiple complex cardiac and neurological diagnoses, including encephalopathy, chronic systolic cardiac failure, ischemic cardiomyopathy, atherosclerotic heart disease, non-rheumatic aortic valve stenosis, and difficulty walking. Upon admission, the resident was using continuous oxygen therapy at 2 liters per minute via nasal cannula, as documented in the admission assessment summary. However, a review of the physician's orders from admission through several days after did not include any order for oxygen therapy. The DON confirmed during interview and record review that the resident's record lacked a physician order for oxygen, despite the resident's continuous use of oxygen during her stay. The DON acknowledged that the licensed nurse should have verified the orders for accuracy and contacted the physician to obtain the necessary order for oxygen therapy, as required by the facility's medication reconciliation policy.