Failure to Obtain Physician Order for Ongoing Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician order for oxygen therapy for a resident with significant respiratory comorbidities and recent hospitalizations for acute respiratory conditions. The resident had diagnoses including end stage renal disease on hemodialysis, COPD, chronic respiratory failure, obstructive sleep apnea, hypertension, bipolar disorder, and anxiety disorder. Hospital records from a recent stay documented sepsis, respiratory acidosis, and acute respiratory failure, with the resident discharged in stable condition while oxygenating well on 2 L via nasal cannula. Despite this, review of the facility medical record revealed no physician order for oxygen therapy upon the resident’s return. The resident’s comprehensive care plan, revised shortly after readmission, included focus areas for COPD, chronic respiratory failure, obstructive sleep apnea, and pneumonia, with goals to maintain oxygen saturation above 90% and normal breathing patterns. Interventions included monitoring for signs and symptoms of respiratory distress and reporting changes to the physician. A subsequent provider note summarized that during several days in January, the resident’s oxygen saturation readings were in the mid-90s "on oxygen," and the resident had recently been hospitalized again for influenza and pneumonia, returning to the facility on antibiotics. However, the Minimum Data Set assessment completed after this hospitalization did not code the resident as using oxygen, and there was still no documented oxygen order in the record. Staff interviews further described ongoing oxygen use without a corresponding physician order. A nurse aide reported that on one evening, the resident was found without oxygen in place and had an oxygen saturation of 68%; after the aide and a medication aide reapplied the oxygen, the saturation increased to around 91–92%. The nurse aide and medication aide both stated the resident had used oxygen before and had needed it more since returning from the hospital, though neither could recall the exact oxygen flow rate. The primary nurse for that shift confirmed that the medication aide had been in and out of the room assisting with oxygen because the resident frequently removed the tubing, and that the resident had been wearing oxygen most of the time since her recent hospitalization. The Medical Director stated that the resident’s oxygen need was on an as-needed basis, but there was no corresponding physician order documented for this oxygen therapy in the facility record.
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