Failure to Enter Physician Order for Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter a physician’s order for oxygen therapy for a resident who was receiving supplemental oxygen. The resident was admitted with COPD, tobacco use, and anemia. On 12/15, the resident was observed asleep in bed on 3 L/min O2 via nasal cannula from a portable tank, without signs of discomfort or respiratory distress. A nurse progress note from earlier that afternoon documented that the nurse notified the provider of abnormal vital signs, including an O2 saturation of 64% on room air, and that the provider ordered oxygen at 2 L/min. The note further stated that the resident’s O2 saturation increased to 89% on 2 L/min, and oxygen was then increased to 3 L/min with saturation rising to 91%. Despite this, review of the electronic medical record that day showed no corresponding oxygen order entered. On the following day, the resident was again observed resting in bed on 3 L/min O2 via nasal cannula, alert and oriented to self and without signs of discomfort or difficulty breathing. A provider progress note documented upper respiratory infection symptoms with difficulty breathing and an O2 saturation of 90% while on 3 L/min O2. Review of the electronic medical record that afternoon again revealed no oxygen order. A subsequent provider note on 12/17 stated the resident had mild upper respiratory infection symptoms during the week, that O2 saturations had dipped below 90%, and that oxygen, antibiotics, and nebulizers were started with improvement in O2 saturation into the low 90s on room air. However, review of the chart at midday on 12/17 still showed no oxygen order. The unit manager, upon reviewing the record with the surveyor, confirmed that the nurse had documented receiving an oxygen order from the provider on 12/15 but had failed to create the required oxygen order in the electronic medical record by 12/17.
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