Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to a resident who required oxygen therapy, as there was no physician's order in place for the administration of oxygen. The resident, an older adult with diagnoses including shortness of breath, obesity, depression, diabetes, and COPD, was observed wearing oxygen at 2 liters per minute via nasal cannula on multiple occasions. The resident's care plan indicated a need for oxygen for shortness of breath and COPD, with instructions for staff to administer oxygen as ordered by a physician. However, a review of the resident's physician orders revealed that there was no order for oxygen therapy at the time of the observations. Staff interviews confirmed that the resident had been receiving oxygen without a current physician's order, and nursing staff acknowledged the importance of having such an order to ensure proper care. The facility's policy required a physician's order specifying the oxygen flow rate, method of administration, usage, and indication for use. Despite this, the order was missing until after surveyor intervention, and staff could not explain why the order had not been entered into the electronic records. The deficiency was identified through observation, interview, and record review.