Oxygen Therapy Provided Without Current Physician Order
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory services in accordance with professional standards of practice for one resident who required supplemental oxygen. The facility’s policy for oxygen concentrator use, revised August 7, 2023, requires verification of a physician’s order when implementing supplemental oxygen. Clinical record review for Resident 97, who had diagnoses including COPD and obstructive sleep apnea, showed a care plan for risk of respiratory complications related to recent hospitalization and COPD, but review of current physician orders did not reveal an active order for supplemental oxygen. During observation, the resident was found lying in bed wearing a nasal cannula and receiving oxygen at 2 L/min despite the absence of a current physician order. In an interview, the DON stated that the resident previously had an order for supplemental oxygen, but it had not been renewed.
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