Failure to Obtain Physician Order and Post Oxygen Signage for Resident on Continuous Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for a resident who was admitted from the hospital on continuous oxygen therapy. Upon admission, the resident had diagnoses including pneumonia and was using an oxygen concentrator via nasal cannula at 2 liters per minute. Review of the resident's admission orders and Minimum Data Set (MDS) revealed no documented order for oxygen use, and the care plan referenced administering oxygen as ordered, but no such order was present. Multiple observations confirmed the resident was receiving continuous oxygen without a corresponding physician's order. Additionally, the facility did not post cautionary 'oxygen in use' signage outside the resident's room, as required for safety. Observations over several days confirmed the absence of this signage while the resident was on continuous oxygen. Interviews with staff, including a medication aide, unit manager, nurse practitioner, and DON, revealed a lack of awareness regarding responsibility for posting signage and a failure to ensure proper physician orders were in place prior to initiating oxygen therapy.