Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to obtain a physician order for the use of oxygen therapy for a resident who was admitted with a urinary tract infection and had moderate cognitive impairment. Despite documentation in the Minimum Data Set indicating the resident received intermittent oxygen therapy during their stay, a review of the admission physician orders revealed no order for oxygen use. Additionally, there was no care plan addressing oxygen therapy for this resident. Multiple staff members, including a CNA and an LVN, confirmed that the resident frequently used oxygen, and a physician's progress note documented the resident being on oxygen via nasal cannula. The Director of Nursing verified that oxygen use is a treatment requiring a physician order and acknowledged that the resident used oxygen without such an order during their stay. Facility policy requires that oxygen orders specify the rate of flow, route, and indication, and that a current list of orders be maintained in the clinical record. The process for obtaining oxygen orders involves the nurse contacting the physician and documenting the order, which was not followed in this case.