Unauthorized and Undocumented Oxygen Therapy Without Physician Notification
Penalty
Summary
Nursing staff initiated and continued oxygen (O2) therapy for Resident #25 without a physician’s order, failed to document the resident’s O2 use, and did not notify the physician when the resident experienced O2 desaturation. Resident #25, admitted with Parkinson’s disease, dementia, and epilepsy, was repeatedly observed over several days seated in a wheelchair and lying in bed with a nasal cannula in place and connected to an oxygen concentrator delivering 2 liters per minute. Record review of the resident’s physician orders on 01/07/26 showed no order for O2 use. Licensed Practical Nurse (LPN) #1 reported that O2 therapy was started after staff noted the resident’s O2 saturation readings in the low 80% range and increasing weakness, but acknowledged that he did not see a physician’s order authorizing O2. LPN #1 further stated that staff were not consistently documenting the resident’s O2 use, O2 saturation levels, or episodes of desaturation, and he was unable to identify documentation of ongoing monitoring, physician notification, or clinical follow-up related to the resident’s O2 needs. The Assistant Director of Nursing (ADON) stated she was unaware the resident had been receiving O2 prior to being informed by LPN #1 shortly before the interview and confirmed she should have been notified when O2 was initiated. The ADON was unable to identify documentation of physician notification, a physician’s order, or supervisory review related to the resident’s O2 use prior to 01/07/26.
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