Oxygen Therapy Provided Without Physician Order or Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving oxygen therapy had a corresponding physician’s order and care plan interventions, as required by facility policy and professional standards. The facility’s oxygen therapy policy dated 3/2012 required a medical order specifying liter flow, route, and frequency, initiation of an “At Risk for Compromised Respiratory Care” care plan with appropriate interventions, and allowed nurses to initiate oxygen only in an emergency with an order obtained within 24 hours. Resident #1, admitted with chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium with metastasis, was documented as minimally cognitively impaired and able to understand and be understood. Record review showed no documented physician’s order for oxygen administration and no documented interventions or goals related to oxygen use in the care plan. Despite the absence of an order, multiple records and staff interviews confirmed that the resident was on oxygen intermittently during the admission. Medication Administration Records documented that on at least two pre-dialysis occasions at 11:00 AM, the resident was using 2 liters of oxygen, and vital sign records showed the resident on 2 liters of oxygen on multiple additional dates. Staff interviews corroborated that the resident routinely used oxygen: the Assistant DON reported seeing the resident returning from dialysis wearing oxygen from a portable tank; an RN stated they removed oxygen from the resident’s face when pronouncing the resident deceased; an LPN reported the resident was wearing oxygen upon arrival to the unit from dialysis; and another RN stated they typically send two oxygen tanks with residents for dialysis or longer trips. The Administrator acknowledged there should have been an order for oxygen, confirming that the resident received oxygen therapy without the required medical order and associated care planning.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.