Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure was observed receiving oxygen at 2 liters per minute via nasal cannula. The resident's care plan included an intervention to administer oxygen at this rate to maintain blood oxygen saturations above 92%. However, review of the physician's order summary and clinical records revealed there was no physician order for oxygen administration, despite documentation and observation confirming the resident was receiving oxygen therapy on multiple dates. Interviews with facility staff, including an LVN, the Executive Clinician, and the Executive Director, confirmed that oxygen therapy should only be administered with a physician's order and that the resident did not have such an order in place. The facility's own policy on oxygen administration also requires verification of a physician's order prior to providing oxygen. The lack of a physician order for ongoing oxygen therapy constituted a failure to provide respiratory care consistent with professional standards of practice.