Failure to Obtain Physician Order for Supplemental Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician’s order for supplemental oxygen before initiating and continuing its use for a resident with COPD. The resident was cognitively intact and not coded as using supplemental oxygen on the most recent MDS, and there was no active order for oxygen in the medical record. Nursing notes documented that the resident developed shortness of breath and was assessed by the Medical Director, who ordered nebulizer treatments and a steroid but did not order oxygen. Despite this, the resident was started on oxygen via nasal cannula at 2 L/min, and this treatment continued over several days without a corresponding physician’s order in the chart. Surveyor observations on multiple days confirmed the resident was receiving oxygen at 2 L/min by nasal cannula. The resident reported she had been placed on oxygen a few days earlier when she had trouble breathing. A nurse stated the resident had previously had an oxygen order that was later discontinued and believed the Medical Director had reordered oxygen, but she could not locate any such order. The Medical Director confirmed he had not ordered oxygen and stated the resident should have had an order before oxygen was initiated. The NP documented in a progress note to continue oxygen after assessing the resident while she was already on 2 L/min, but she did not review the active orders and did not realize there was no oxygen order in place. The DON acknowledged the resident’s prior oxygen order had been discontinued and that staff should have obtained a new order before restarting oxygen.
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