F0695

D

Failure to Obtain and Enter Physician Order for Supplemental Oxygen

Warrenton, North Carolina Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and enter a physician order for supplemental oxygen for a resident who required respiratory support. The resident was admitted with cellulitis of the right lower leg and pneumonia and was cognitively intact, with the admission MDS indicating no use of supplemental oxygen. On one occasion, the resident complained of shortness of breath and was found to have oxygen saturation levels in the 80s on room air. Nurse #3 applied 2 L of oxygen via nasal cannula, which improved the saturation to 94–96%, and documented that the provider was notified via electronic communication. However, a review of the physician orders showed no order for supplemental oxygen for this resident.

Nurse #3 reported that she did obtain an oxygen order from the provider but had difficulty entering it into the system and did not realize it had not been successfully entered. She stated that she usually could “fumble” through entering orders and that Support Nurses normally entered physician orders, so she did not frequently perform this task. She did not notify a Support Nurse or seek assistance when she encountered difficulty entering the oxygen order. The Support Nurse assigned to the resident stated that the nurse who obtained an order was responsible for entering it and acknowledged she did not think to review the resident’s orders to ensure the oxygen order was present. The DON confirmed that Nurse #3 was responsible for notifying the provider and entering any orders for supplemental oxygen and stated that Nurse #3 should have reached out to her or another nurse for help when having difficulty entering the order. At the time of observation, the resident continued to receive 2 L of oxygen via nasal cannula without a corresponding physician order in the record.