Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure was administered oxygen at 2 liters per minute via nasal cannula without a physician's order. The resident's care plan included oxygen therapy, and clinical records documented ongoing oxygen administration on multiple dates. However, review of the physician's order summary revealed no order for oxygen administration, despite the resident receiving it regularly. Observations confirmed the resident was receiving oxygen, and staff interviews acknowledged the absence of a physician's order for this treatment. Facility staff, including an LVN and the Executive Clinician, confirmed that oxygen therapy should only be provided with a physician's order and that the lack of such an order could result in unmonitored treatment. The Executive Director also stated that all treatments, including oxygen, require a physician's order and proper documentation in the clinical record and care plan. The facility's own policy on oxygen administration requires verification of a physician's order prior to providing oxygen, which was not followed in this case.