Failure to Ensure Physician Indication for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a physician's indication for oxygen administration was present for a resident who was receiving respiratory care. The resident's electronic medical record documented diagnoses of dementia, anxiety, and depression, with a recent assessment indicating intact cognition. The care plan included interventions for assistance with repositioning and noted functional limitations, but did not provide direction for nursing staff regarding oxygen therapy. The physician's order for oxygen administration specified the use of oxygen per nasal cannula as needed and monitoring of oxygen saturation, but did not include a diagnosis or indication for the use of oxygen. During interviews, both a licensed nurse and an administrative nurse confirmed that oxygen, as a medication, requires a diagnosis for administration, and that the current order lacked this necessary information. Observations showed the resident present in common areas, but there was no documentation or care plan guidance related to the use of oxygen therapy. The facility's own policy required physician orders for oxygen to include the rate, route, mask, and frequency, but the order in question did not meet these requirements.