Failure to Ensure Current Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received such care in accordance with professional standards, the comprehensive care plan, and the resident's goals and preferences. The resident, who had diagnoses including acute respiratory failure, pneumonia, thrombocytopenia, and chronic atrial fibrillation, was admitted with a need for supplemental oxygen. The baseline care plan indicated the resident was confused, removed the nasal cannula, and required frequent redirection for oxygen therapy. However, the facility did not have a current physician's order for oxygen administration during the resident's stay. The only available order was from a previous admission, and staff administered oxygen based on this outdated order. Interviews with nursing staff and facility leadership revealed that the outdated order was mistaken for a current one due to similar admission dates, and the discrepancy was not identified during the admission or order transcription process. The Director of Nursing and other staff acknowledged the importance of verifying and following current physician orders, but the oversight resulted in the resident receiving oxygen therapy without a valid, current order. The facility's policy required medications and treatments to be administered as prescribed, but this was not followed in this instance.