Failure to Obtain Physician Order and Document Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Upon readmission, the resident, who had a history of cerebrovascular accident, seizure disorder, asthma, COPD, respiratory failure, and severe cognitive impairment, was observed receiving oxygen via nasal cannula without a corresponding physician's order. The resident's comprehensive care plan and medical record did not reflect any order for oxygen use, and the Medication Administration Record (MAR) also lacked documentation of oxygen therapy or its settings. During observation, the resident was found in bed with an oxygen concentrator that was beeping and displaying a yellow alarm, and the flow indicator was not visible. Nursing staff adjusted the oxygen flow to 2 L/min after responding to the situation. Interviews with nursing staff and facility leadership confirmed that the resident was receiving oxygen as needed, sometimes adjusting the flow independently, and that there was no physician's order in place for this therapy. Both the DON and the Administrator acknowledged that oxygen is considered a medication and requires a physician's order, and that orders are necessary to guide care. Facility policy also requires verification and implementation of physician orders for oxygen administration, with documentation of resident response. The lack of a physician's order for oxygen use and absence of documentation in the care plan and MAR constituted a failure to provide care consistent with professional standards and facility policy.