Failure to Obtain Timely Physician Order for Continuous Oxygen Therapy on Admission
Penalty
Summary
Surveyors determined that the facility failed to obtain a physician’s order for oxygen therapy upon admission for a resident who required continuous oxygen. The resident was admitted with diagnoses including pneumonia and acute respiratory failure with hypoxia. Discharge instructions from the sending provider specified oxygen therapy at 2 L/min via nasal cannula on a continuous basis, with monitoring of oxygen saturation and supplemental oxygen as needed to maintain a goal saturation of 92%. The admission/readmission comprehensive nursing assessment documented an oxygen saturation of 98% via nasal cannula, indicating that the resident was receiving oxygen at the time of admission. Review of the Medication Administration Record for the admission month showed an order for oxygen at 3 L/min via nasal cannula, continuous, with a start date two days after the resident’s admission. During interview, the DON stated that an oxygen order should begin on admission when a resident needs it and acknowledged that the resident was wearing oxygen but that the order was not entered into the medical record until two days later. The DON further stated that the facility’s policy on oxygen administration, which requires verification of a physician’s order before the procedure, was not followed by the nurse because there was no oxygen order from admission.
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