Failure to Follow Physician Orders and Oxygen Therapy Policy
Penalty
Summary
Surveyors identified that a resident with diagnoses including Alzheimer's disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease was receiving oxygen therapy without a corresponding physician order or care plan. On observation, the resident was found lying in bed with oxygen running at 2 liters via nasal cannula, and the oxygen tubing lacked a date label indicating when it had been changed. During interviews, the Wound Care Coordinator stated that oxygen tubing should be labeled with the date to ensure cleanliness and for infection control, and the DON acknowledged that oxygen administration requires a physician order and that tubing should be dated. The facility’s oxygen therapy policy, last revised 12/1/2021, requires verification of a physician order prior to oxygen administration and directs staff to discard disposable masks, cannulas, and tubing after use in accordance with an equipment change schedule, which was not followed in this instance. The deficiency centers on the facility’s failure to follow its own oxygen therapy policy and physician order requirements, resulting in oxygen being administered to the resident without an active physician order, without a documented care plan for oxygen use, and with unlabeled oxygen tubing that did not comply with the facility’s infection control and equipment change procedures.
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