Oxygen Administered Without Physician Order
Penalty
Summary
A resident with a history of heart failure, seizures, and chronic kidney disease was admitted to the facility and was observed receiving 3 liters of oxygen via nasal cannula. The resident's baseline care plan indicated he was to receive oxygen, and previous hospital records confirmed he was on continuous oxygen prior to admission. However, upon review of the resident's current physician orders, there was no documented order for oxygen administration. Nursing staff confirmed that the resident was receiving oxygen but acknowledged the absence of a physician's order in the chart and were unsure why it was missing. Facility policy requires a physician's order for oxygen administration, as oxygen is considered a drug. The policy also mandates documentation of oxygen use in the medical record, including the order, reason for use, and resident response. Despite these requirements, the resident was administered oxygen without a corresponding physician's order, and this was confirmed through observation, record review, and staff interviews.