Failure to Obtain Physician Order and Post Oxygen Use Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of atherosclerotic heart disease was admitted to the facility and began receiving oxygen therapy without a physician's order. The hospital discharge orders did not include oxygen therapy, and there was no documentation in the physician progress notes or the electronic medical record (EMR) indicating an order for oxygen. Multiple nurses documented that the resident was receiving oxygen via nasal cannula, but none recorded the amount of oxygen administered. Interviews with nursing staff revealed confusion and lack of recall regarding the presence of an oxygen order, with several staff members acknowledging that an order should have been obtained and entered into the EMR but was not done until several days after admission. Additionally, the facility failed to ensure that appropriate signage indicating 'oxygen in use' was placed outside the resident's door while the resident was receiving oxygen therapy. Nursing documentation and staff interviews confirmed that the signage was not posted, and staff could not recall why this step was missed. Observations confirmed that the resident was receiving oxygen therapy without the required signage being present on the door. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect documentation of oxygen use for the resident during the period in question. Interviews with the Director of Nursing and other team leaders confirmed that it was the responsibility of nursing staff to ensure both the physician order and the signage were in place when oxygen therapy was initiated. The deficiency was attributed to oversight and lack of communication among the nursing staff and team leaders during the admission process.